This book is dedicated to Kevin, Nina, Hildegard, Birger, Holger, Gunder, Ingo and Patrick Joyce, John, Christine and Bruce

Acquisitions editor: Heidi Allen Development editor: Myriam Brearley Production controller: Chris Jarvis Desk editor: Jane Campbell Cover designer: Fred Rose

Butterworth-Heinemann Linacre House, Jordan Hill, Oxford OX2 8DP 225 Wildwood Avenue, Woburn, MA 01801-2041 A division of Reed Educational and Professional Publishing Ltd A member of the Reed Elsevier plc group First published 1985 Reprinted 1987, 1990 Second edition 1992 Reprinted 1995, 1997 Third edition 2001 © Reed Educational and Professional Publishing Ltd 2001 All rights reserved. No part of this publication may be reproduced in any material form (including photocopying or storing in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright holder except in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1P 0LP. Applications for the copyright holder’s written permission to reproduce any part of this publication should be addressed to the publishers Every effort has been made to contact Copyright holders requesting permission to reproduce their illustrations in this book. Any omissions will be rectified in subsequent printings if notice is given to the Publisher British Library Cataloguing in Publication Data Boscheinen-Morrin, Judith The hand: fundamentals of therapy – 3rd ed. 1. Hand – Surgery – Patients – Rehabilitation 2. Hand – Wounds and injuries – Patients – Rehabilitation I. Title II. Conolly, W. Bruce 617.5 75 Library of Congress Cataloguing in Publication Data The hand: fundamentals of therapy/[edited by] Judith Boscheinen-Morrin, W. Bruce Conolly. – 3rd ed. p. cm. Includes bibliographical references and index. ISBN 0 7506 4577 6 1. Hand – Wounds and injuries – Patients – Rehabilitation. 2. Hand – Surgery – Patients – Rehabilitation. 3. Hand – Diseases – Patients – Rehabilitation 4. Physical therapy. I. Boscheinen-Morrin, Judith. II. Conolly, W. Bruce. RD559.B67 617.5 75–dc21 00-051928 ISBN 0 7506 4577 6

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Foreword

When ‘The Hand: Fundamentals of Therapy’ was first published in 1985, the importance of this subject was only just starting to be appreciated. Since that time, hand therapy has grown to be a well-recognized and respected specialty. Nowadays, it would be a short-sighted surgeon indeed, who did not acknowledge the vital role that the therapist plays in the overall management of patients with disorders of the hand. This book has fulfilled an important task in delineating this role, and the fact that it is now in its third edition, bears witness to its success. In this latest edition, new chapters have been added to cover the important topics of the wrist and free

tissue transfer. At the same time, existing chapters have been updated to keep pace with the rapid changes that are occurring in the fields of hand surgery and therapy. While intended primarily as a guide for the nonspecialist, I believe that this book has a wider appeal. Not only does it provide an excellent quick reference for anyone involved in treating patients with disorders of the hand, it also offers the sort of clear and simple overview of a specialized subject that will make it attractive to students and trainees as well. Timothy J. Herbert, FRCS, FRACS March 2000

continue to be the cornerstones of successful patient management. in condensed form. Careful clinical assessment. While diagnostic evaluation. This third edition aims to highlight. . the current thinking and practice in hand surgery and therapy.Preface That hand surgery and therapy have become such areas of specialization (and even sub-specialization) comes as no surprise when one considers the extent to which the hand is represented within the homunculus. The hand therapy programmes emphasize treatment techniques that can be used by the patient outside the formal therapy milieu and thereby encourage self-reliance early in the rehabilitation process. surgical procedures and therapeutic techniques have become increasingly sophisticated. the formulation of a treatment plan and regular patient review. the basic principles and practices of aftercare remain unchanged.

St Luke’s Hospital and NSW Private Hospital. Sydney Hospital.S. Sydney. Australia Dr James Masson. Sydney Hospital. St Luke’s Hospital. Consultant Plastic Surgeon. B. FRACS (Plastics) Consultant Hand Surgeon. Sydney. Australia. Sydney.Sc. Sydney.App. South West Hand Therapy.(Hons) UNSW. FAOrthA Consultant Surgeon. MB. MAHTA. (OT) Hand Therapist. Liverpool Hospital. FRACS. Australia Dr Peter Scougall. Australia . Concord Hospital.Contributors Jacki Shannon-Johnstone. B.

Dr Lionel Chang. . and Nina and Kevin Morrin for their enhancement of the text with line drawings. for providing clinical photographs. David Robinson and Karen Spragg for their assistance with the development of prints. Dr Peter Scougall and Dr James Masson for their chapter contributions. for making available clinical slides for reproduction. for her contribution to the two previous editions. and the many patients who so willingly subjected themselves to photographic sessions. ‘Tad’ for his role as anamchara. The authors would like to acknowledge and thank their erstwhile colleague. Jo Munro-Hick and Dr James Masson for assistance with proofreading. Victoria Davey. Dr Ian Isaacs. both wonderful past mentors. Caroline Makepeace and Zoe Youd of Butterworth-Heinemann for their assistance and encouragement during manuscript preparation. and to Jacki Shannon-Johnstone for the many ways in which she has shown great generosity of spirit. ‘Lola’ for her words of inspiration. Jacki Shannon-Johnstone. Helen McElhone and Anne Smidlin. Nina and ‘Nanny Hildegard’. Jacki Shannon-Johnstone. Director of Sydney Hospital Hand Unit.Acknowledgements Heartfelt thanks are extended to the following individuals who have helped bring this book to fruition: Becci Boscheinen. Special gratitude is reserved for those on the home front – Kevin. who have helped ‘carry’ this book in every sense of the word.

sympathetically maintained pain STT. total passive range of motion TROM. triangular fibrocartilage TFCC. carpometacarpal CRPS. extensor digiti minimi EDQ. flexor digitorum profundus FDS. osteoarthritis ORIF. flexor pollicis longus FR. scapho-trapezial-trapezoid TAROM. oblique retinacular ligament PA. extensor digitorum communis EDM. torque range of motion UCL. flexor digitorum superficialis FPL. position of safe immobilization PROM. triangular fibrocartilage complex TPROM. total active range of motion TCL. systemic lupus erythematosus S-L. extensor digiti quinti EIP. transcutaneous electrical nerve stimulation TFC. active range of motion CLIP. activities of daily living AP. open reduction and internal fixation ORL. pronator teres RA. scapholunate SMP. visual analogue scale VISI. distal interphalangeal joint DISI. extensor carpi ulnaris EDC. dorsal intercalated segment disability DRUJ. first dorsal metatarsal artery FDP. sympathetically independent of pain SLAC. volar intercalated segment instability . flexor carpi ulnaris FDMA. extensor carpi radialis brevis ECRL. capitate-lunate instability pattern CMC. proximal interphalangeal joint PL. posterior interosseous nerve PIP. extensor carpi radialis longus ECU. transverse carpal ligament TENS. interphalangeal K-wire. chronic regional pain syndrome CT. computed tomography CTS. posteroanterior PIN. distal radioulnar joint ECRB. flexor retinaculum IP. minimal active muscle-tendon tension MCP. scapholunate advanced collapse SLE. extensor pollicis longus FCR. anteroposterior APL. rheumatoid arthritis SIP. abductor pollicis longus AROM. passive range of motion PT. Kirschner wire MAMTT. metacarpophalangeal MRI. carpal tunnel syndrome DIP. electromyography EPB.List of abbreviations ADL. ultrasound VAS. flexor carpi radialis FCU. extensor pollicis brevis EPL. magnetic resonance imaging NCV. nerve conduction velocity OA. palmaris longus POSI. extensor indicis proprius EMG. ulnar collateral ligament US.

but also in music and the arts. 3. e. This allows it to conform to the multishaped objects that it needs to grasp (Tubiana. Paul Brand reminds us of the need ‘to balance objective assessments with trusting our impressions and to resist our tendency to reject considerations of things that we cannot quantify’ (Brand.1 Assessment Introduction The hand demonstrates remarkable mobility and malleability. in patients presenting with de Quervain’s disease.e. Clinical assessment The formulation of a treatment programme is based on a full assessment that gleans both objective and subjective data. The most important aspect of the history. The symptoms resulting from the injury or condition and their pattern of behaviour. frequency and intensity. i. The hand links us intimately to others through touch. 1984). Most patients will require only a limited selection of all the tests that are at the therapist’s disposal (Fess. As important as our objective findings are. carpal tunnel syndrome. trigger finger or a closed wrist injury. Associated health problems. it is an organ of expression that is used to convey emphasis and to communicate language. The history should include the following details: 1. The hand is a unique tool of accomplishment.e. The abundance of receptors in the skin of the palm distinguishes the hand from other areas of the body. The hand has 19 intrinsic muscles and about the same number of tendons whose origin is in the forearm. 5. age. The mechanism of the injury. 2. for example. be no obvious outward signs of injury or deformity as. i. work and leisure activities and family particulars. diabetes.g. after amputation of a digit or contracture associated with Dupuytren’s disease. The hand and wrist contain 27 bones (19 miniature long bones and 8 carpal bones). Where hand pathology is complex. it is preferable to perform assessments over a number of sessions to avoid fatigue and stress. the hand alone is capable of simultaneously touching as it is being touched (Brun. This will sometimes be obvious. The recency of the injury or condition. 4. There may. not only in our everyday domestic. hand dominance. should therefore be tailored to the unique needs of each patient. Just as importantly. is the reason that the patient has come for treatment. 1998). 1963). There are 17 articulations involving the digits. however. e. 6. The treatment programme . 1995). Unlike these other areas. however.g. The assessment repertoire includes the following: History Every history begins with the patient’s pertinent details. Previous treatments and their effect. work and leisure activities. Prescribed medications.

elbow and forearm.1). shiny skin of the thumb and index finger following injury to the median nerve. sharp objects or friction. 2.g. is assessed first. Tactile examination The following are assessed by touch and will confirm much of what has been noted in the visual examination: Figure 1. 7.g. Muscle wasting.2 The Hand: Fundamentals of Therapy Physical examination The physical examination has both a visual and a tactile component. 1. Restricted joint motion. Nerve damaged skin is very prone to injury from heat. 3. 10. It is remarkable how often features that may appear abnormal to the examiner. Deformity e. ultrasound (US).3). Skin mottling. i. trophic lesions may be present (Fig. Note also the loss of normal skin creases over the joints. This patient developed chronic regional pain syndrome (Type 1) within weeks of surgery which involved repair of an extensor tendon. e. flexion deformity of the proximal interphalangeal (PIP) joint (Fig.e. 11. Much can be gleaned simply by looking at the hand. red or cyanosed). Swelling and pain were the main initial features of his condition. excessive sweating or dryness. 9. brittleness or ridging. computed tomography (CT). Wounds.1. the texture of the skin may appear smooth and shiny with loss of pulp ridging and pulp wasting. magnetic resonance imaging (MRI)). Relevant X-rays or scans should also be viewed by the therapist (e. pressure. Figure 1. . comparison is always made with the patient’s other hand. Flexion deformity at the PIP joint is the commonest deformity seen in the hand. 1. The mobility of the more proximal upper limb joints. Circulation (the hand may be pale. Note the smooth.g. 1.3. 8. 4. Hand oedema is common following injury. Swelling: where this is marked swelling there will be loss of normal skin creases (Fig. shoulder. 5. Note the loss of MCP joint flexion and flexed posture of the PIP joints. Nail deformity.2. Visual examination The hand is inspected for presence of the following: 1. Soft tissue contracture. swannecking. Scars (recent and old).2). lateral deviation of a digit or joint hypermobility are normal manifestations of both hands. During examination. Figure 1. It is also associated with a number of conditions that can affect the hand. 6.

Swelling The skin is indented to determine whether oedema is soft and yielding (usually acute) or ‘woody’ and dense (subacute or chronic). e. Soft tissue tightness The forearm and hand are palpated for soft tissue tightness that may be limiting movement at the wrist and/or finger joints. 2.g. e. generally. duration and sources of .g. should be recorded in the patient’s history. Thickenings or nodules The palm is palpated for thickenings or nodules that are not apparent on visual inspection. protracted flexion splinting can result in muscle-tendon shortening.g. i.Assessment 3 3.4. burning. 5. magnetic resonance imaging. Temperature of the skin Increased temperature may indicate inflammation/ infection or early-stage chronic regional pain syndrome (CRPS). 4. The patient should indicate whether the pain is localized or radiating and whether it is deep or superficial. Adherence of tendons can also affect the hand’s normal tenodesis effect whereby flexion of the wrist will facilitate finger extension and conversely. 6. The intensity. stabbing. however. Figure 1.g. it can be a sign of CRPS. the latter does not augur well for conservative treatment outcome. nerve conduction studies. excessive dryness is a feature of nerve damage. extension of the wrist will facilitate finger flexion. Scar condition Palpation of the scar will determine areas of hypersensitivity and whether the scar is supple and mobile or rigid and adherent. an arthritic joint or tendonitis. where there is a neuroma. thickening of the A1 pulley (trigger finger) or tight fascial bands or nodules that may indicate early Dupuytren’s disease. Joint stiffness Joints are passively moved to determine whether they have a ‘springy’ or ‘hard’ end-feel. The patient is asked to describe the nature of the pain.. ultrasound. Pain 1. e. etc. Pain is difficult to assess clinically because its experience is unique to each individual. decreased temperature may be a sign of poor circulation (e. Raynaud’s disease). 8 Palpation of the hand This may identify painful areas. All relevant X-ray findings and results from diagnostic tests. Moistness or dryness of the skin Excessive sweating (hyperhidrosis) is normal in some patients. 7.e. bone scans.g. following nerve and flexor tendon repair at the wrist. e. shooting or aching. nerve injury or later-stage CRPS.

5. Figure 1. 1993). tendon inflammation (e. following repair or significant injury). Total passive range of motion (TPROM) As for TAROM except that an external force is used to move the digit. Pain that persists can be ‘graded’ on a linear pain scale of 0–10. Composite finger flexion to the palm This measures the distance of the finger pulp from the palm when all three finger joints are flexed simultaneously. such as the examiner’s hand. . 1.g. Torque range of motion (TROM) Torque range of motion involves moving a joint passively through its range of motion using a constant force. tendon constriction (e. around 800 g.g. 1993). tendon subluxation or dislocation. in the case of corrective splinting. 1.5). The objective of torque angle range of motion is to provide a more objective PROM assessment (Brand. 2. Passive range of motion (PROM) This refers to the arc of motion that is achieved when an external force. with ‘0’ representing no pain and ‘10’ representing the severest level of pain.or proximal-palm area (Fig. 4. the finger pulp will lie over the distal palmar crease. Total active range of motion (TAROM) This refers to the total flexion range of a digit when its three joints are flexed simultaneously and any extension deficit over the three digital joints is subtracted. 3. e. in the acutely swollen digit or hand where an increase in joint mobility occurs inevitably as oedema is resolved. bearing in mind that the active motion of the joint will be limited by the joint’s passive capacity. Where flexion range is more restricted.g.g. the finger pulp will lie over the mid. e. Range of motion is also recorded to compare preand postoperative results. To measure the force applied during passive motion. 5.4 The Hand: Fundamentals of Therapy provocation are also recorded (Echternach. Brand advocates the use of a Haldex gauge. e. Active range of motion (AROM) This refers to the arc of motion that is achieved when the muscles that control a joint are used to move it. Where flexion range is nearnormal. This information is important in determining whether treatment measures are achieving the desired result. Breger-Lee and others (1990) also use the Haldex gauge and in their research have noted that higher force levels. after prolonged immobilization. 6. is used to move the joint. This visual analogue scale (VAS) can be used before and after treatment sessions as a guide to determine the efficacy of treatment. Factors that can influence a joint’s passive range include disruption of the articular surfaces (intra-articular fracture) and/or capsular fibrosis. In everyday clinical practice. i. rheumatoid disease or overuse). 1995). provide more consistent correlations during interphalangeal joint measurements. Composite finger flexion can be assessed with a ruler that measures the distance from the pulp of the finger to the palm.g. a spring scale or a pushpull device calibrated in grams up to one kilogram. both active (AROM) and passive range of motion (PROM) should be recorded. Rigorous recording is less relevant in conditions where improvement in ROM is anticipated. Acute postinjury or postoperative pain is to be anticipated and generally passes uneventfully. Range of motion Range of motion can be determined in a number of ways (Cambridge-Keeling.g. trigger finger or de Quervain’s disease). tendon adhesion (e. Causes of limited active range of motion can include: loss of tendon continuity.e.

Figure 1. Positioning of the hand during measuring The position of the forearm and hand should be consistent during each recording. a hook grip.8). 1974) (Fig.6). Thumb web span or interdigital span can be measured with a ruler. 7. will best facilitate measurement of the DIP joints. To optimize accuracy when assessing range of motion. 1.. restriction of finger flexion when the wrist is maximally flexed and restriction of finger extension when the wrist is maximally extended. 1. the contact of the goniometer arms with the skin should be as intimate as possible. The goniometer can be placed laterally or dorsally. This position eliminates the possibility of restricted tendon glide due to the tenodesis effect. To ensure optimum accuracy.6. The author believes that there is less margin for error in dorsal placement and therefore prefers this method. proper placement of the goniometer is not always possible.e. the contact of the goniometer arms with the skin should be as intimate as possible (Perry and Bevin. i. When measuring flexion range of the distal interphalangeal joint (DIP) joint during global flexion. The arm of the goniometer used to measure the wrist and forearm is about 15 cm in length compared to the 4–6 cm arm needed to assess digital range of motion (Fig.7). 1969). It is important that the fulcrum is centred over the joint and that the arms of the goniometer lie over the long axes of the adjacent bones. The size of the goniometer should be appropriate to the joint being measured.8. 1.e. the wrist should be held in neutral and the forearm in pronation. Goniometer placement To minimize intertester error.Assessment 5 Figure 1. The patient is therefore asked to slightly extend the metacarpophalangeal (MCP) joints to accommodate goniometer placement. a specific protocol should be adopted (Hamilton and Lachenbruch. Figure 1. The size of the goniometer should be appropriate to the joint being measured. the goniometer will require an arm of at least 15 cm in length. Thumb or finger web spans These can be measured with a ruler by determining the distance between the tips of the various digits (Fig.7. Full extension at these joints. Assessment of motion with a goniometer Joint range of motion can be reliably assessed with a goniometer (Hellebrandt et al. For wrist and forearm assessment. . 1949). When measuring finger joint ROM. i.

To monitor recovery of sensibility after nerve repair. . the patient may be deliberately perpetuating a swollen hand for secondary gain. oedema subsides uneventfully in response to simple measures such as elevation. 1. OTR. e.9.9). For example. If oedema is noted to fluctuate for no apparent reason. To determine the extent of sensory loss following a nerve lesion. 2. If the minus sign appears before extension range. Sensibility testing Cutaneous sensibility refers to the conscious appreciation and interpretation of a tactile stimulus (Fig. This fluctuation may indicate an impending pain syndrome or rarely. 1.10). When the water settles after rising. The tank is filled to a known level and the hand and wrist are held vertically and placed into the tank to a predetermined level marked circumferentially on the forearm. at the PIP joint. a battery of tests should be used Figure 1. e. To assist in the diagnosis of neuropathies. Objective assessment of sensibility is difficult.g.e. 1988). –20/105. Oedema assessment Oedema can be assessed simply with a tape measure that is applied at specific anatomical landmarks.g. 4. such as the ‘Volumeter’ designed by Dr Paul Brand and Helen Wood. This is due in part to the subjective responses of the patient and to the fact that there is considerable variation in the application of force and velocity during hand-held examination techniques (Bell-Krotoski and Buford. 1991). the difference in volume is recorded. in Louisiana (Waylett-Rendall and Seibly.6 The Hand: Fundamentals of Therapy Method of recording Range of motion is usually expressed as extension/ flexion. Hand and finger oedema can be assessed with a tape measure that is applied at specific anatomical landmarks. there may be an indication for formally recording these changes. e. Types of tests Because no single test can adequately assess sensibility. In other words. i. 5. In most cases. The reasons for assessing sensibility include: 1. In everyday clinical practice. Even the results of nerve conduction velocity tests can be influenced by factors such as the size and placement of electrodes. at the PIP joint of the single digit or around the MCP joints when assessing hand oedema (Fig. To determine the most suitable time to initiate sensory re-education (i. the assessment of hand or finger swelling has little relevance. with 0 degrees regarded as neutral. A more formal method of measuring changes to oedema is by means of water displacement when the hand is immersed in a large Perspex container. 3. temperature of the extremity and even the time of the day that testing occurs. light compres- sion bandaging and the commencement of early active movement where this is not contraindicated.e. carpal tunnel syndrome. a total active range of 85 degrees. To help determine the degree of functional impairment for medicolegal purposes.g. 20/105 degrees of active movement at the PIP joint of the right index finger would denote a 20 degree flexion deformity and 105 degrees of flexion. upon return of moving touch). this would denote a 20 degree range of hyperextension at the PIP joint.

diminished protective sensation and loss of protective sensation) and can be used without sacrificing test sensitivity (BellKrotoski. ulnar and radial nerve innervation. normal. (Callahan. 1. Light touch sensibility is a prerequisite for performing fine discriminatory tasks while deep pressure is a form of protective sensation.Assessment VOLAR ASPECT DORSAL ASPECT 7 Median nerve Ulnar nerve Ulnar nerve Palmar cutaneous branch of ulnar nerve Palmar cutaneous branch of median nerve Radial nerve Figure 1. Threshold tests The two threshold tests are vibration and touchpressure (Semmes-Weinstein monofilaments).11). diminished light touch. but also how acuity relates to functional ability (Bell-Krotoski. The lightest monofilament exerts a 4. 1999). cold. 1. Sensibility tests can be divided into various categories. 1995. Semmes.g. This will help determine not only sensory acuity. 1999). The smaller set of five monofilaments represents the highest calculated force of each functional sensory level and can be used without sacrificing test sensitivity. 1995). e. that occurs in compression syndromes (Dellon. Clark. Both tests are used to detect the gradual change in nerve function . other sensibility tests. threshold tests. Semmes-Weinstein monofilaments The ‘light touch-deep pressure’ monofilament test is regarded as one of the most objective for cutaneous sensibility assessment (Table 1). tactile gnosis tests or objective tests. A smaller set of five monofilaments represents the highest calculated force of each functional sensory level (i. Based on von Frey’s pressure sensibility test for warmth. Weinstein and others (1960) developed a testing instrument to assess somatosensory changes in adults following brain damage. such as static and moving two-point discrimination (which are innervation density tests).10. Figure 1. Sensory distribution in the hand showing the areas of median. innervation density tests. When assessing compression syndromes.e. 1980) and that does not involve cortical integration (Szabo. 1967). will not register changes until much later. 1993) (Fig. The monofilaments are calibrated to exert specific pressures. This testing system was then adopted by von Prince for assessment of the nerve-injured hand (von Prince and Butler.11. pain and touch.5 mg force while the heaviest filament exerts a 447 g force. The full testing kit includes 20 colour-coded nylon filaments. each mounted in a Lucite rod. The monofilament test is helpful in monitoring return of sensibility following nerve repair.

Twopoint discrimination is considered to relate to the hand’s ability to perform fine tasks such as winding a watch or threading a needle (Moberg.65 (Red-lined) *Miniset monofilaments are in bold. 1981). 2. Interpretation Normal light touch Diminished light touch Diminished protective sensation Loss of protective sensation Untestable (no response) Force (g) 0. The hand is stabilized (exercise putty is ideal for this purpose) and vision is occluded (Fig.166–0. The examiner can commence the test with a higher numbered filament where sensibility is very poor.1. Each filament is applied to the same spot on three occasions.63–447 Greater than 447 Technique This test requires the patient’s full concentration and should therefore be carried out in a quiet environment.13). 1. Instruments used for this test include the Boley Gauge. The hand can be effectively stabilized with putty during monofilament testing. following nerve repair.83.31 (Purple) 4.65 (Red) Greater than 6.12). 1973).696–2. 1958).84–4. all relevant areas of nerve distribution should be assessed. Each filament is applied to the skin perpendicularly for 1–1. When monitoring progressive nerve compression. 1.65–2. Because nerve conduction velocity is slowed with low temperatures (de Jesus et al. An affirmative response is recorded if one of the three applications elicits a response.56–6.g. Innervation density tests Static two-point discrimination.22–3. as should the patient’s hand during testing. the testing room should be warm. Semmes-Weinstein monofilament scale of interpretation Filament 1. The response is then recorded on the grid pattern with the appropriate colour and dated for later comparison (Fig. The area of sensory dysfunction is mapped out and the test is begun with filament 2. For other conditions. This test is only relevant in the tips of the fingers where discrimination is required (Fig. Figure 1. .5 s until it bends.61 (Blue) 3. Grid pattern for recording results of monofilament testing of light touch-deep pressure sensibility.. e.408 0. free of distractions.5 s and then lifted in the same timeframe. the ‘Disk-Criminator’ or a paper clip.068 0. Figure 1.13.12. The filament is held for 1–1.14).0045–0. 1. moving two-point discrimination and localization are innervation density tests (also referred to as functional tests) that require complex cortical integration.8 The Hand: Fundamentals of Therapy Table 1. testing can be confined to the volar digital pulps where receptor density is most concentrated (Moran.83* (Green) 3.052 3.

(c) Point localization Point localization is assessed using the lowest numbered filament that the patient is able to perceive during light touch testing. screw.2. The procedure is timed and comparison is made with the opposite hand. The patient picks up a number of objects as quickly as possible and places them in a box. coin.Assessment 9 Figure 1. The Moberg pickup test (Moberg. (b) Moving two-point discrimination When assessing moving two-point discrimination. 1978). 1958) and Dellon’s modification of this test (1981) require the patient to . nuts and bolts. 3. follow-up testing should show fewer and shorter arrows (Callahan. To record an accurate response. Following nerve repair. 7 out of 10 responses must be correct. Two-point discrimination norms* Normal Fair Poor Protective Anaesthetic Less than 6 mm 6–10 mm 11–15 mm One point perceived No points perceived *American Society for Surgery of the Hand Guidelines.14. Table 1. return of moving two-point discrimination precedes static two-point discrimination by several months. safety pin. the filament is applied to the hand. paper clip. The patient is then asked. 1995). (a) Static two-point discrimination With vision occluded. 2. the test is commenced with a point-to-point distance of 5 mm. The ‘Disk-Criminator’ is used to test two-point discrimination in the tips of the fingers.15. With vision occluded. Two-point discrimination in the hand* Pulp of the thumb Pulp of the index finger Pulps of the other digits Base of the palmar aspect of the digits Thenar and hypothenar eminences Midpalmar region Dorsal aspect of the digits Dorsal aspect of the hand *After Tubiana.3. Where the response is incorrect. As sensibility improves. 1984. to identify the point of contact with the other hand. Tactile gnosis tests These tests require active patient participation and involve everyday objects such as a key. marble. with eyes open. testing is carried out in a proximal to distal direction with the instrument initially set at a distance of 8 mm (Dellon. 2 or 5 mm if the response is incorrect (Callahan. 1983). Figure 1.5–5 3–5 4–6 5–6 5–9 11 6–9 7–12 mm mm mm mm mm mm mm mm Table 1. the grid is marked with an arrow from the point of stimulation to the area where the touch has been referred (head of arrow). The ‘pick-up test’ is a test of tactile gnosis that requires some motor dexterity. The points are applied longitudinally with minimal pressure that should not cause blanching. The distance between the points is increased by 1. The correct response is then recorded with a dot on a grid pattern such as that used for recording light touch.

e. This sensation. each of which influence the strength of Figure 1. pins and needles) experienced by the patient when the nerve is percussed is caused by regeneration of the sensory axons which are very sensitive to pressure. The test is repeated every few weeks. the elbow flexed to 90 degrees. While the test has limited functional value (it can be elicited even where there are only few regenerating fibres). The Jamar dynamometer is a reliable tool for assessing grip strength.e. Tinel’s sign should be interpreted in the light of other clinical findings. 1954) on the condition that calibration of the instrument is maintained. Tinel’s sign Nerve regeneration can be monitored by Tinel’s sign which was described in 1915 by both Tinel and Hoffman. This procedure is timed and comparison is made with the uninvolved hand. the examiner gently percusses along the course of the nerve in a distal to proximal direction. is not painful and should be felt peripherally in the cutaneous distribution of the nerve rather than at the point of direct pressure. their results do not correlate directly with sensibility during nerve regeneration. 1973). this time with vision occluded. although this timeframe can vary significantly according to the severity of the lesion. Percussion is continued until paraesthesia is elicited. Technique Using the tip of the finger.16. patients who are unable to comply with formal testing or those suspected of malingering. there is no correlation (Phelps and Walker. Dellon standardized the original test items by choosing objects of a similar material (i. Where motor dexterity is adequate to perform the test. while in the case of nerve compression syndromes. whilst unpleasant.e. 4. areas of the hand that are not used due to poor sensibility. 1. the test is discontinued. While these tests can be indicative of sensory function. A good prognosis is suggested where distal progression of the sign is noted. The test is performed with the shoulder adducted. Grip strength measurement 1. it is useful in confirming axonal growth. . all metallic) to avoid providing clues that can be gained through variation in texture and temperature. The paraesthesia (i. i. The wrinkle test involves placing the hand in warm water (40ºC) for a period of 30 min (O’Rain. According to Tinel. Note is taken of the manner in which the patient handles the objects. The dynamometer has five handle positions. These tests are considered useful in the assessment of children. it is repeated. the sign appears about 4 to 6 weeks after injury. the forearm in neutral rotation and the wrist in 0–30 degrees of extension and slight ulnar deviation. If the patient lacks the ability to manipulate the objects because of poor motor function. 1977). Objective tests These tests include the Ninhydrin sweat test and wrinkle test and require no patient participation as they rely on a sympathetic response.15). The sweat test identifies areas of disturbed sweat secretion and can be carried out with commercially available Ninhydrin developer and fixer.10 The Hand: Fundamentals of Therapy pick up objects as quickly as possible and place them into a box while sighting the objects (Fig. Power grip Power grip strength can be reliably assessed with the Jamar dynamometer (Bechtol.

second.17. (2) lateral pinch where the thumb is clasped against the radial side of the index finger (strongest pinch grip) and (3) three-jaw chuck where the pulp of the thumb is pinched against the pulps of the index and middle fingers.e. fifth and first (Fess. No evidence of contraction.16). no joint movement. forearm in neutral rotation. Complex injuries or conditions such as rheumatoid arthritis will require full functional assessments involving all aspects of the patient’s life. the test is repeated three times and the average reading is recorded (Fig. The ‘second handle’ position was recommended as the test position in 1978 by the ‘Clinical Assessment Committee of the American Society for Surgery of the Hand’. To determine precisely which muscles have been affected following a nerve lesion. (3) three-jaw chuck pinch between the thumb and index and middle fingers (as above). Muscle contraction producing movement with gravity eliminated. is absent. 2. 1. 1. Readings diminish in the following ‘handle position’ order: third (strongest). As for power grip. 3. The test is performed three times with a short rest period allowed between readings so that the result is not affected by fatigue. These assessments may need to be carried out at regular intervals as the patient’s functional status alters. 4. to enable grasp. 1. the discrepancy is greater than 20 per cent (it may be much higher). (2) lateral (or key) pinch between the thumb and radial aspect of the index finger. 1995). 5. toothbrush or razor. Muscle contraction producing movement against full resistance. Psychological assessment The hand and psyche are inextricably linked (Grant. wrist between 0 to 30 degrees of extension and in slight ulnar deviation. that is noted when testing in each of the five positions. Grading of strength is as follows: 0. The commonest aid involves the enlargement of small handles. The normal bell curve of grip strength. i.. 2. A pinch gauge is used to assess the three pinch grip positions: (1) tip-to-tip pinch between the thumb and index finger. In helping to monitor motor progress during nerve regeneration.Assessment 11 grip (Fig. fourth. Muscle contraction producing movement against gravity. 1980). e. cutlery. 2. 1982). Muscle contraction producing movement against gravity with some resistance. i. Where indicated. 2. aids can be provided on a temporary basis to encourage early use of the hand.g. 1971) is indicated in the following circumstances: 1. Figure 1. As a preoperative evaluation in determining which muscles can be utilized for tendon transfer. The readings are quite erratic. The average of the readings is then recorded. A patient is suspected of fudging the results if: 1.17). elbow flexed to 90 degrees. The psychological responses following hand . Pinch grip strength Pinch grip strength is assessed with a pinch gauge which assesses (1) tip-to-tip pinch between the thumb and index finger (weakest pinch). home.e. Manual muscle testing Manual muscle testing (Kendall et al. The testing position is as follows: shoulder adducted. work and leisure. 3. Functional assessment The patient is assessed for any problems relating to routine activities of daily living (ADL). Evidence of slight muscle contraction. the result will be a flat curve with each of the readings being very similar (Aulicino.

The reliability of goniometry in assessing finger joint angle. Callahan. The force/time relationship of clinically used sensory testing instruments. Am. 1(2). M. La Main et I’Esprit. D. Hunter. Thesis (MSc. Mosby. Brand. (1981). Hunter. 1(4). eds) pp. (1995). – Coursework).. 454–76. Hunter. J. L. Bell-Krotoski. 565. Mackin and A. J. Brand. Hand Ther. 3. Fess. Ther. Mackin and A. 474. The effects of Jamar dynamometer handle position and test protocol on normal grip strength. Brand and A. Phelps. 615. Where injury to the hand has been serious. C. L. (1977). (1973). J. Grant. E. Reconstr. F. Breger-Lee. 223–53. E. Br. Moberg. J. Moran. A. The moving two-point discrimination test: clinical evaluation of the quickly-adapting fiber/receptor system J. (1984) Sensibility testing: clinical methods. 7–13. (1999). Unpublished Masters Thesis. M. Phys.12 The Hand: Fundamentals of Therapy Callahan. 36A. (1974). Mosby. G. C. In Rehabilitation of the Hand: Surgery and Therapy (J. Kendall. Hellebrandt. W. J. Prac. Muscle Testing and Function. Plast. A. L. eds) pp. 5. Mackin and A. A. F. L. References Aulicino. Hunter. Curtin University of Technology. J. Phys.. Grip test: use of a dynamometer with adjustable handle spacing. Rev. 54. P.. Dellon. J. (1988).. While these reactions are normal in the short term. 185–214. Comparison of sensory testing methods using carpal tunnel syndrome patients. Ther. A. and Wadsworth. Kendall. J. (1993). E. G. 23. Bell-Krotoski. D. 26–9. J. E. Callahan. D. Callahan. Torque range of motion in the hand clinic. 3. eds) pp. Callahan. L. de Jesus. Phys. Surg. J. Reliability of goniometry. Duvall. 417–9. Williams & Wilkins. W.. M. J. Documentation: Essential elements of an upper extremity assessment battery. M. Callahan. 465. A. Apart from the possible financial implications of being unable to work. M. (1973). . Clark. F.. 2(3). In Rehabilitation of the Hand: Surgery and Therapy (J. H. 29. G. (1995). (1971). 65. eds) pp.. In Rehabilitation of the Hand: Surgery and Therapy. Hamilton. ‘Pocket filaments’ and specifications for the Semmes-Weinstein monofilaments. Cultural factors may play an important role as does a patient’s premorbid personality or pre-existing psychological problems. Sensibility testing: current concepts. (1995). E. 14–26. J. The hand and the psyche. E.. Phys. D. 7... H. Cambridge-Keeling.. Occ. Hand Ther. Hand Surg. (1963). and Barchi. Mosby. Schneider. P. eds) pp.. The effect of cold on nerve conduction of human slow and fast nerve fibers. the dynamics of the patient’s family and social life are also radically altered. E. 76. and Buford. (1982). P. T. 109–28. A. D. (1954). and Moore. the repercussions for the patient can be enormous. J. Part III. Mackin and A. D. (1995). Hand Ther. Hollister. 1182. A. Williams & Wilkins. J. In Rehabilitation of the Hand: Surgery and Therapy (J. (1995). J. Mosby Year Book. J. Neurology. P. and Brandsma. Mosby. J. E. Bone Joint Surg. 40B. N. 593. Sensibility assessment: prerequisites and techniques for nerve lesions in continuity and nerve lacerations. 3(1). 145–7. New and simple test for nerve function in the hand. D. O’Rain. Fess. Hand Ther. eds) pp. 407–31. Others are more affected by potential loss of function and what this will mean in relation to work and recreational activities. To some patients. (1958). Comparison of the finger wrinkling test results to establish sensory tests in peripheral nerve injury. Perry. Range-of-motion measurement of the hand. Mosby. (1993). (1949). J. (1980). Procedures of the American Society of Hand Therapists. Bechtol. trauma vary considerably and can be complex. E.. L. Bell-Krotoski. Medical College of Virginia. Evaluation procedures for patients with hand injuries. Evaluation of Sensibility and Re-education of Sensation in the Hand. W. (1998). (1980). In Rehabilitation of the Hand: Surgery and Therapy (J. Hausmanow-Petruse-Wics. The measurement of joint motion. their persistence should be taken seriously and appropriate psychiatric intervention should be arranged. S. (1969).. and Walker. C. E. D. Mackin and A. 2nd edn (J. G. Hand Surg. I. 129–52. Mosby. J. 820. Callahan. Clinical evaluation of pain. D. J. 2nd edn (P. F. Mackin and A. and Lachenbruch.. In Rehabilitation of the Hand: Surgery and Therapy (J. P. 31. Hunter. (1993). A. Bone Joint Surg. P. eds) pp. Digital nerve repair: the relationship between sensibility and dexterity. L. Med. and Bevin. Virginia Commonwealth University. W. (1990). J. J. D. (1978). Dellon.. 308. Clinical examination of the hand. Hunter.. Bell-Krotoski. Methods of clinical measurement of the hand. (1981). 53–75. The mental/emotional state of the patient should be monitored closely for persisting signs of anxiety and/or depression. H. J. Brun. 49. Hand Surg.. Callahan. Presses Universitaires de France. E. The mind and spirit in hand therapy. Jr. altered body image results in serious loss of self-esteem and emotional disturbance. J. M. E.. Ther. A. R. E. Echternach. Dellon. M. Clinical use of vibratory stimuli to evaluate peripheral nerve injury and compression neuropathy. 93–107. 3. An individual’s reaction to injury is not always in proportion to the extent of physical damage. In Clinical Mechanics of the Hand. 466. Ther. Ther. Objective methods for determining the functional value of sensitivity in the hand. 302.

J. Waylett-Rendall.) pp. ed. 13 Tubiana.. K. (1984). Med. and Seibly. J. 388–9. P. Harvard University Press. (1915).. R. R. 385. 21. .. Saunders. J. and Butler. In Green’s Operative Hand Surgery (D. R. A study of the accuracy of a commercially available volumeter. von Prince. Measuring sensory function of the hand in peripheral nerve injuries. L. 1–97.. B. Somatosensory Changes after Penetrating Brain Wounds in Man. 4(1). D. Weinstein. (1991). In Examination of the Hand and Upper Limb (R. 47. 1404–47. Occ. Am. N. B. Le signe du ‘fourmillement’ dans les lesions des nerfs peripheriques. Green. and Teaber. Ther. Tinel. Ghent. Szabo. Press. J. W.. (1967). H. M. (1960). Architecture and functions of the hand.Assessment Semmes. Hand Ther. 10–3. Entrapment and compression neuropathies. S. Tubiana. Churchill Livingstone. Pederson. C. J. L. (1999). Hotchkiss and W. eds) pp.

The oedema associated with these conditions is referred to as ‘transudate’ and is caused by increased hydrostatic pressure. partly through tissue distension and partly from irritation of the nerve endings by substances contained within the exudate. e. the effect of drugs (e.2 Treatment principles and tools Introduction Care of the hand following injury or surgery aims to restore function without compromising the healing process. This clotting process precipitates fibrin formation and the creation of a network of fibres that joins the sides of the wound together. however. 1984). 1986). causes disruption of capillary integrity. The three phases of healing are: 1. 1992). The inflammatory or exudative phase (the first 3 to 4 days) The inflammatory phase is characterized by oedema. redness. The oedema resulting from injury is different to that associated with medical conditions such as chronic heart failure. 1995). blood flow is arrested by a short period of vasoconstriction. the timetable of these events is fairly predictable. steroids).g. Injury to the hand. This oedema is low in protein (Witte and Witte. increased fibroplasia and scarring can ensue. 1971) and causes minimal fibroplasia. The surface of the wound is usually covered by the third day as epithelial cells migrate into the wound from the basal layers of the epidermis. Phases of wound healing No matter what the wound type. Where the inflammatory phase of healing is prolonged through careless wound handling or too early or vigorous movement. At the time of injury. This . pain. This inflammatory exudate causes pain. Where healing is uncomplicated. heat and pain. Blood flow then ceases as a result of platelet aggregation. To formulate an aftercare programme. This is followed by the growth of new capillary buds that bridge the wound. kidney disease or postmastectomy lymphoedema (Hardy. Devitalized tissue and debris is then cleared from the wound by leuocytes and macrophages in a process known as phagocytosis (Smith. This is followed by vasodilation when histamine is released into the injured area and there is an increase in blood flow and the leaking of plasma into the wound region. the healing process is achieved by a series of complex events that are interlinked and interdependent. disease (e. the therapist needs to appreciate the various phases of wound healing and the implications for treatment that are inherent in each of these phases. cold exposure or emotional stress (Hunt and Hussain. Wound healing can be influenced by many factors: infection. The potential for adhesion formation is therefore negligible. prostaglandins (Peacock. Propensity for adhesion is therefore high.g. diabetes).g. The exudate that leaks from damaged vessels is a protein fluid that is rich in fibroblasts.

Dressings that tend to dehydrate. 1989) and advances the process of angiogenesis. 1976. Madden and Peacock. they stop moving due to a recognition process called ‘contact inhibition’. 1977). When the migrating cells meet each other. thick and unyielding.g. as the wound is still thin and fragile. The newer ‘microenvironmental’ dressings.16 The Hand: Fundamentals of Therapy migration follows converging paths from every part of the wound edge. overzealous exercise and excessive pressure should be avoided. Where appropriate. however. This network provides the fibroblasts with oxygen and nutrients so that they are able to synthesize collagen properly. Pressure to scar is maintained during this period. With time. The mitotic rate of epithelial cells at the wound surface is about 40 times higher than that of uninjured tissue (Hugo. the scar may be raised. e. Short-term use of analgesics may be indicated. becoming paler. Lyofoam. The initial gel-like . Wound cover prevents fluid loss and provides a barrier against infection (Peacock. the paraffin gauzes. 2. The key cell during this phase is the fibroblast. 1971). The formation of granulation tissue is dependent on a network of blood vessels being formed in the injured tissue bed (i. Management The wound is now able to withstand the stress of gentle active movement. are difficult and painful to remove (particularly in the case of fingertip injuries) and can disrupt or retard the healing process. This is a connective tissue cell that synthesizes and secretes collagen and other intercellular substances required to produce new tissue. are used for specific types of wound and maintain an environment that promotes healing. the scar will soften. Protective splinting will need to be maintained in certain circumstances. e. Intrasite and Duoderm. (b) To reduce pain Dressings that maintain wound humidity decrease pain and reduce mechanical trauma when the dressing is removed. the tissues of the hand are in a state of reduced nutrition and inelasticity where adhesion formation can readily ensue (Hunter and Mackin. oedema reduction is a priority after injury or surgery. 1995). 3. thereby decreasing the size of the wound. The rapid rise in tensile strength during this period parallels the increase in collagen content although the wound still has less than 15 per cent of its ultimate strength at this time (Madden. Oedema management may still be necessary and remains a priority until it is eliminated. This process of wound contraction has usually been achieved by the third week. These specialized fibroblasts have the contractile properties of smooth muscle cells and exert a central pull on the wound edges. flatter and more pliable. red. Supportive splinting and elevation will help reduce pain by relieving tissue distension. This is achieved with gentle compressive dressings and elevation above heart level. thereby restoring the thickness of the epidermis. Remodelling or maturation phase The remodelling phase lasts a minimum of 6 months but can continue for up to 2 years. The wound is further protected with supportive bandaging or splinting. 1984). gentle active finger movement is commenced. They then continue to divide. Fibroplastic or regenerative phase This phase of healing begins after about the 5th day and can last from 2 to 6 weeks depending on the extent of the wound. The wound gradually becomes stronger as the amount of collagen decreases although the tensile strength of scar tissue is never more than 80 per cent of that of uninjured skin. A subpopulation of fibroblasts become myofibroblasts. angiogenesis). This phase sees a decrease in fibroplastic activity and a shutdown in mitotic activity.e. ongoing production of new collagen and the removal of old collagen. A capillary network has usually formed by the end of the second week.g. Tegaderm. Where significant oedema persists. At the beginning of this phase. following tendon repair. Maintenance of wound humidity enhances cellular activity (Alvarez. Aims of treatment (a) To protect the vulnerability of the wound Wounds should be covered with dressings that prevent fluids escaping from the wound bed.g. Scar remodelling is characterized by the rapid. e. (c) To promote resolution of oedema To minimize the potential for fibrosis and scarring.

This means that the patient must be handled with great care. 1976). the frail elderly. 6. Wound care. children. i. motivator. 5. The therapist has a variety of treatment tools at his or her disposal. is important in: 1.e. Splinting. Selfreliance is an essential component of psychological and emotional well-being and is encouraged as soon as the patient is ready. possible budget restraints and the requests of the referring surgeon. Sensibility assessment/retraining. The home programme is a vital part of the rehabilitation process. occupational or physiotherapist).Treatment principles and tools 17 collagen with its randomly arranged fibrils and low tensile strength is gradually replaced with stronger and more highly organized collagen. Choice of treatment modalities will be influenced by the professional and clinical background of the therapist (i. Ideally. The process of scar remodelling is favourably influenced by the application of low-load forces that are applied at the appropriate time (Arem and Madden. 4. where there is a language difficulty or where patients feel unable to cope with the aftercare programme. 10. While this list is by no means exhaustive. Patient education is therefore an important element in management. 3. 8. stiffness or scar. Desensitization. the most important treatment tool is the therapist. Oedema control. Pain management. Nerve gliding exercises. It is at this time that the patient’s trust and confidence will need to be engendered for therapy to proceed. Exercise Movement. Helping eliminate oedema through compression and relaxation of the hand’s tissues. 4. both physically and psychologically. Clinical aspects of treatment The therapy programme will need to address at least one. Stiffness. they should be written down and accompanied by easily understood line drawings for home reference. it will address most of the clinical problems that the therapist is likely to encounter. pain. 7.e. 1. this section describes each modality in turn rather than management of individual clinical problems. There are occasions when family involvement will be required. swelling. The therapist At the patient’s initial session. Scar management. 3. This is achieved through splinting and pressure therapy. Maintaining the gliding function of tendons and nerves. both passive and active. These are also modalities that the patient is able to use away from the formal therapy environment. Assessment and treatment should be as pain-free as possible and instructions to the patient should be clear and few in number. Swelling. Scar. Pain. Exercise. These situations include: the complex hand injury. of the following: 1. Management It is during this stage of high collagen turnover (2 to 4 months postinjury) that clinical treatment methods can exert their greatest influence and hence optimize functional outcome. This is especially important following major trauma where a protracted rehabilitation process is anticipated. Psychological support. 9. 11. The therapist also plays an important role in providing emotional support and as a . 2. if not all. 2. Tools of treatment Hand injuries or conditions invariably present with one or all of the following: 1. Functional activity. 2. Maintaining joint mobility. 3. Specific treatment modalities The treatment modalities described below are those that the author believes are indispensable to hand therapy practice. Because many of these modalities can frequently address several clinical problems simultaneously.

however. These signs will usually manifest themselves within minutes of application and indicate that the wrap needs to be removed and reapplied. Where appropriate. Movements should. Passive movements need to be performed with great care to avoid exacerbating or causing pain and inflammation.g. Figure 2. In the early phase of therapy. Coban wrap should be replaced if it becomes wet. Patients are given a specific number of repetitions to perform. pain. where not contraindicated (e. rather than stretched onto the finger (Fig. 2. be carried out in a systematic fashion that does not merely involve wriggling the fingers. Active exercise Active movement. This is especially true where dorsal hand skin is ‘taken up’ by oedema with the effect of limiting global flexion.1. is begun as soon as possible after injury or surgery. Where possible. (ii) throbbing and (iii) numbness or paraesthesia. Individual stabilized movements generally result in a greater arc of motion than do composite joint movements. A single layer is applied in a distal to proximal direction with negligible tension. This is particularly important in the acute phase of management. inflammation and oedema are not exacerbated.18 The Hand: Fundamentals of Therapy Figure 2. Stabilized joint movement promotes differential tendon glide and generally results in a greater arc of motion. Patient instruction in its application is most important so that circulation is not compromised. active exercise is commenced as soon as possible after injury or surgery. 5 to 10 movements every 1 or 2 hours. inflammation or swelling. It is used: (a) To control oedema Acute digital oedema is effectively managed with the narrowest Coban wrap. 2. e. so that the Coban is lain.g. This entails stabilizing the joint or joints proximal to the joint being moved (Fig. movements should be performed in a stabilized manner so that differential tendon glide can occur. the narrowest of which is 25 mm. Coban wrap Coban wrap is a thin. passive exercise should precede active exercise so that the muscle-tendon unit does not have to overcome the resistance of a stiff joint. 2.2. Signs that the wrap has been applied too tightly include: (i) discoloration of the fingertip. exercise sessions are brief and frequent but should not exacerbate pain. it is best if patients are taught to carry out their own exercises. Unless contraindicated. Passive exercise Passive exercises should be performed with great care so that again. This is particularly important in tendon rehabilitation (Fig. For this reason. following tendon repair). passive exercises are best performed by the patient who will generally perform them to a pain-free limit. For this reason. Its sheerness makes it particularly suitable for use with fingers as it does not impede interphalangeal joint motion.1). particularly when oedema is present. . self-adherent elastic wrap that comes in various widths. 2.2).3).

rigid or soft. supportive or corrective.or fingerbased. Coban wrap can facilitate increased interphalangeal joint range of movement through its pain-relieving effect. e. Wider sizes of wrap can be applied to the dorsum of the hand.g. A single layer is applied in a distal to proximal direction under negligible tension. the radial nerve palsy splint that facilitates the reciprocal tenodesis effect) (Fig. (c) To help manage scar The intimate contact that Coban wrap has with the skin makes it ideal for early pressure therapy over digital scar.e. the static ‘spaghetti’ splint for correction of ulnar ‘claw’ deformity . (d) To relieve pain Patients frequently report pain relief when some form of gentle elastic support is applied to the area in question. static or dynamic. This is referred to as serial casting or splinting.Treatment principles and tools 19 Figure 2.5) or to prevent joint and soft tissue contracture by controlling deformity and restoring balance in nerve lesions. they can behave dynamically when the splint is applied at the maximum range of joint movement or maximum soft tissue stretch. Its initial role of protection and support is gradually supplanted by its corrective role in overcoming soft tissue and joint contracture. however. an elastic wrist brace to support a painful wrist (Fig. 2.3. more economical alternatives include the use of an elastic crepe bandage or a single or double layer of appropriately sized tubular stockinette. 25-mm-width). Figure 2. Types of splint Splints can be categorized in a number of ways.4). 2. Splinting Hand splinting is an integral part of therapy during each phase of healing. The skin tolerates this wrap very well and it is relatively easy to remove and replace. Splints can be used to optimize function by positioning the wrist and/or fingers when muscle power is absent (e. however. Static splints are generally used to provide support and protection. 1987) and because oedema is more comfortably accommodated in this flexed position. a flexion deformity can quickly ensue.g. unlike a dynamic splint which applies force through rubber bands or coils. A static splint has no moving components.e. The gentle elastic tension of Coban wrap not only helps eliminate oedema but also exerts a mild extension force in the acute phase of treatment (e.4. Gentle elastic support often provides pain relief. volar or dorsal and forearm-.g. after phalangeal fracture or Zone II flexor tendon repair). The PIP joint is a common location of pain in the hand. Acute digital oedema is most effectively managed with the narrowest Coban wrap (i. hand. e. The normal resting position of this joint is between 30 to 40 degrees (Bowers. both of which can be the consequence of significant injury. i.g. (b) To help prevent a PIP joint flexion deformity The anatomy of the PIP joint favours flexion. Coban wrap is ideal for holding dressings in place as its minimal bulk allows greater ease of interphalangeal joint movement. 3.

This splint has a corrective function in overcoming PIP flexion deformities in the range of 15 to 35 degrees (Fig. application and wearing regimen (Fess. Prior to splint application. The dynamic hand-based Capener splint is manufactured from piano wire. 1995). hand or digit so that shear forces are avoided (Wilton. This is best achieved by covering a larger area. To maximize patient compliance. 2. The Capener splint is an example of a finger-based dynamic splint. 1995). straps should be sufficiently wide and be angled to the contour of the forearm. the viscous property of connective tissue must be subjected to a load of adequate intensity (Cyr and Ross. be easy to don and doff. the patient will need to be educated in relation to the splint’s purpose. mobility. Slings used in dynamic splints need to pull at precisely 90 degrees if shear forces to the digit are to be avoided (Fig. 1998). thermoplastic material and adhesive moleskin.20 The Hand: Fundamentals of Therapy Figure 2.5. Splinting is ‘the only available therapeutic modality that applies controlled gentle forces to soft tissues for sufficient lengths of time to induce tissue remodelling without causing detrimental microscopic disruption of cellular structures’ (Fess and McCollum. Likewise. the splint should be simple in design. It is preferable to err on the side of caution when splinting is begun so that tissue response can be monitored for any sign of swelling or inflammation. corrective splinting is mandatory in achieving optimum functional results.6). This forearm-based radial palsy splint restores the reciprocal tendosesis action of wrist extension-finger flexion and wrist flexion-finger extension. The timeframe for this will vary from patient to patient. 3. It is fashioned from piano wire. Also. 1995). Splinting for tissue remodelling Where exercise and soft tissue techniques prove insufficient in restoring joint and soft tissue 1. 1995). Principles of splinting Figure 2. intermittent splinting should be maintained throughout the remodelling phase until the tendency for relapse has been overcome. A minimum of 6 months is recommended. The static portion of a dynamic splint should cover a sufficient area to ensure stability so that . The remodelling process cannot be achieved unless this gentle force is maintained over a period of weeks (and sometimes months). patients should be encouraged to persevere for 12 to 18 months where the tendency for recidivism is high. This splint is effective for overcoming PIP joint flexion deformities of 35 degrees or less.7).14). (see Figure 5. The splint should provide the minimum possible pressure so that the tissues of the hand can tolerate prolonged wear where necessary. 1997). 2. Forces ranging from 100 to 300 g are recommended for correcting contractures of the small joints of the hand (Brand. When the desired result has been achieved. 2. be free of pressure areas and be as cosmetically pleasing as possible.6. thermoplastic material and moleskin (see Colditz. The tissue must be held under tension that is higher than its resting tension and must be applied continuously if permanent elongation of skin and other soft tissues is to occur (Bell-Krotoski and Figarola. 1998). however.

2. (a) When applying dynamic traction. 4. Figure 2. e.7. the MCP joint is stabilized when an outrigger is applied to correct a PIP joint flexion deformity (Fig. When applying a flexion force to the digit.9). . the fingers converge towards the scaphoid bone. Skin is checked for signs of pressure areas or excessive sweating which may lead to skin maceration. 1997). Protect areas of hypersensitivity due to scar or a neuroma. During flexion.9. Corrective splints are removed regularly throughout the day so that active movement and function can be maintained. migration or rotation does not occur when forces are applied. this natural orientation will need to be accommodated. (b) Where the line of pull is not at 90 degrees.g. Help to eliminate oedema. In the case of this dynamic outrigger to the PIP joint. 6. the fingers converge toward the scaphoid bone. Soft splinting Soft splinting refers to the use of soft materials such as neoprene (Clark.8. Microfoam). The joint proximal to the joint being mobilized needs to be well stabilized. 5. When applying a flexion force to the digit. These materials can address the following clinical problems: 1.11). a shear stress to the digit or hand segment will occur. the MCP joint has been stabilized in extension. 5. bandages (for flexion bandaging) or taping (e. the line of pull should follow this natural orientation (Fig. During flexion. 4.g. the line of pull should be at a right angle to the axis of the skeletal segment being moved. Exert a gentle corrective force to stiff or contracted joints (Figs 2. 2. Figure 2. 2.Treatment principles and tools 21 Figure 2. 3. The joint proximal to the joint being mobilized will need to be well stabilized so that the corrective force that is applied remains constant. lycra.10 and 2.8). Tolerance to splinting will need to be carefully assessed during the first few days. Provide support and warmth to a painful joint. Flatten scar that is raised or hypertrophic.

The extension force that a lycra glove can transmit through the interphalangeal joints is readily observed when a gloved and ungloved hand are compared. Microfoam (3M) tape makes an excellent interphalangeal joint flexion strap. Fingerstalls and wrist/thumb wraps can be manufactured in minutes.22 The Hand: Fundamentals of Therapy Figure 2.10. Because neoprene does not fray when cut. For example.11. . 2. It is soft. These fabrics are relatively economical. The ‘extension force’ of a lycra glove becomes apparent when a gloved and ungloved hand are compared. An older style sewing machine can be purchased at low cost and is able to handle thicker fabrics with ease. it is a very practical material to work with. 3. Advantages of neoprene and lycra 1. The sewing machine has become almost as integral to splinting as have the heating pan and heat gun.12.13). a neoprene fingerstall to correct a PIP joint flexion deformity can be worn around the clock without interfering with function because the fingertip can remain free and the stall allows virtually unrestricted flexion range (Fig. seams are worn to the outside. flexible and lightly adhesive. in the painful hand they can be effectively used as a first-stage ‘extension splint’ prior to the fitting of a ‘hard’ splint (Fig. 5. Soft splints can be used in combination with thermoplastic splinting.12). A crepe bandage (minimum 10 cm width) makes an excellent flexion wrap. 2. Its effectiveness is augmented when the hand is immersed in warm water. A high comfort factor ensures excellent patient compliance. Figure 2. To avoid pressure on the skin. 4. While lycra gloves are usually fitted to overcome hand oedema. Figure 2. The risk of pressure areas is negligible (particularly with neoprene). 2.

A neoprene fingerstall can make an effective ‘extension’ splint when continuously worn.15. It also helps eliminate digital oedema and provides effective compression to scar. . hand scars are generally quite small. Initial wearing times should be restricted to about 4 h so skin reaction to the gel can be assessed. Figure 2. It can be used on its own or worn beneath a compression glove. Reaction is rare and will usually manifest as small red dots that resemble a heat rash. Cica-care gel is ideal for use on the hand because. This. it should be held in place with tubular stockinette or paper tape (e.14. Micropore) so that it is not lost. 4. 2. combined with the fact that the gel can be reused for some weeks. Gentle scar massage and percussion exercises initiate the desensitization process. The patient is encouraged to ‘handle’ the scar regularly throughout the day. makes it a cost effective treatment (Fig. Silicone gel for scar management Clinical studies have demonstrated the benefits of silicone gel sheeting in the prevention and treatment of hypertrophic scar (Katz. The gel is worn at least 12 h each day for 6 to 8 weeks in ‘non-aggressive’ scar and for up to 6 months where scar is hypertrophic or keloid. Although the gel is adhesive. Figure 2. although this product is quite expensive.13. The skin should be ‘aired’ regularly to avoid maceration and the gel washed in a mild soapy solution at least once a day. Care should be taken to rinse and dry the gel thoroughly before reapplication.14). the effectiveness of these stalls and garments far outweighs this slight disadvantage and is of little concern to most patients. clean and dry. 1992). It is thought that hydration of the scar may reduce collagen deposition by decreasing capillary activity (Davey et al. All traces of massage cream or oil should be removed prior to its application. Figure 2. tubular stockinette or Coban. Silicone gel is the most effective treatment for raised or hypertrophic scarring. The gel is applied to skin that is healed. 1991).g.Treatment principles and tools 23 While not entirely cosmetic..

24

The Hand: Fundamentals of Therapy

Figure 2.16. Silicone-lined fingerstalls help soften scar, shape the stump and provide protection.

Figure 2.17. Opsite Flexifix is used to provide relief of pain and hypersensitivity related to scar, neuroma, fingertip injury, stumps, causalgia related to CRPS and paraesthesia associated with nerve regeneration. In this case it is used to lessen scar hypersensitivity following open carpal tunnel decompression.

Apart from impacting on the scar’s topography and rendering it flat, pale and supple, the gel decreases pain and acts as a ‘shock absorber’ to sudden contact. The author believes that use of silicone gel is superior to scar massage as a treatment to soften scar. Scar massage is beneficial as a desensitizing exercise and to moisturize the skin. 5. Opsite Flexifix Opsite dressings have been known to relieve pain when applied to wounds (Neal et al., 1981). Pain relief from contact of Opsite on unbroken skin in diabetic patients with painful neuropathy was anecdotal until a study was undertaken by the Diabetic Department of King’s College Hospital in London (Foster et al., 1994). This study concluded that Opsite reduced pain in a significant number of patients with painful diabetic neuropathy. While the pain of neuropathy results from a disease process rather than direct nerve or soft tissue injury, the types of symptoms commonly described by hand patients are common to both

pathologies, i.e. shooting (lancinating), burning (causalgia), pins and needles (paraesthesia) or the extreme contact discomfort known as allodynia (Boscheinen-Morrin and Shannon, 2000). Rationale It is thought that Opsite may act in a similar way to transcutaneous electrical nerve stimulation (TENS) in that continuous contact of the film with the skin may stimulate the large, light touch A-beta afferent fibres and, in doing so, inhibit the nociceptive activity of the small A-delta and C-fibres, i.e. Melzack and Wall’s ‘gate-control theory’ (Melzack, 1973). The product Opsite Flexifix (i.e. ‘Opsite on a roll’) is a nonsterile version of the original Opsite dressing. Opsite is an adherent polyurethane film which is waterproof and permeable to oxygen and water vapour. It is used in conjunction with ‘Skin-Prep’ wipes which enhance adhesion of the film to the

Treatment principles and tools

25

skin. Opsite Flexifix is available in two widths. The narrower version, i.e. 5 cm roll, is more suitable for use on the hand. Indications for use 1. Fingertip injuries. 2. Amputation stumps. 3. Causalgic pain associated with chronic regional pain syndrome. 4. Neuroma. 5. Scar hypersensitivity. 6. Paraesthesia associated with nerve regeneration. The film is applied as soon as skin has healed. It is well tolerated by the skin and often remains in place for several days before needing to be replaced. Its sheerness and elasticity mean that movement is not affected when the film is applied across joints. Its use after fingertip injuries is ideal as sensibility is not impeded. The finest monofilament can be detected through the film. Opsite can be used beneath silicone gel. Even when used on its own, Opsite has a positive influence on scar as it exerts a gentle compressive force. 6. Transcutaneous electrical nerve stimulation The advantage of TENS over other forms of pain relieving treatment is that pain relief is ongoing and not therapy dependent. Sensory level stimulation, i.e. conventional TENS (high pulse rate and narrow pulse width) delivers a therapeutic current

to the cutaneous sensory afferent fibres. The amplitude is monitored to ensure that no muscle contraction is evident (Fig. 2.18). Electrodes should only be used on skin that is intact and has sensation. TENS is not used by patients with pacemakers. Electrode placement is often a matter of experimentation. Electrodes should not be placed immediately over the painful area. The electrode is placed over the peripheral nerve, proximal to the site of pain or injury or on either side of the area (i.e. proximal and distal). The current is increased gradually until the patient perceives a comfortable level of stimulation which is continued for 30–60 min at a time. A carry-over effect is often experienced for several hours. The unit is reapplied when this effect begins to diminish. Some specific indications for use 1. Causalgic (burning) pain associated with chronic regional pain syndrome (Types 1 and 2). 2. Neuritis following surgery or injury, e.g. irritation of the superficial branch of the radial nerve after surgery for Colles’ fracture or decompression of the first dorsal compartment for de Quervain’s syndrome.

Figure 2.18. Transcutaneous electrical nerve stimulation can be particularly effective in managing neuritis that can follow surgical procedures, causalgia associated with CRPS or neuroma pain.

Figure 2.19. The most common functional aid involves the enlargement of handles. This is achieved easily and economically with different sizes of insulation tubing.

26

The Hand: Fundamentals of Therapy

3. Hypersensitivity decompression. 4. Neuroma.

following

carpal

tunnel

It is important that patients do not over-exercise or overuse the hand during periods of pain relief. Exercises and activity are carried out slowly and gently and response is monitored prior to upgrading the therapy programme. 7. Aids to daily living Until a functional range of motion has been restored, it can be helpful to modify the small handles of everyday utensils. This is achieved simply and economically with insulation tubing usually referred to as ‘Handitube’ (Fig. 2.19). This product is available from most major hardware stores. For patients with ongoing functional limitation and/or weakness, many excellent laboursaving devices are now available from department stores.

References
Alvarez, O. (1989). Moist environment in healing: Matching dressing to wounds. Wounds, 2, 59. Arem, A. and Madden, J. (1976). Effect of stress on healing wounds: Intermittent noncyclical tension. J. Surg. Res., 20, 93. Bell-Krotoski, J. A. and Figarola, J. H. (1995). Biomechanics of soft tissue growth and remodeling with plaster casting. J. Hand Ther., 8(2), 131–7. Boscheinen-Morrin, J. and Shannon, J. (2000). Opsite Flexifix: An effective adjunct in the management of pain and hypersensitivity in the hand. Aust. J. Occ. Ther., (submitted September, 2000). Bowers, W. H. (1987). The anatomy of the interphalangeal joints. In The Interphalangeal Joints (W. H. Bowers, ed.) pp. 13–20, J. B. Lippincott. Brand, P. W. (1995). The forces of dynamic splinting: Ten questions before applying a dynamic splint to the hand. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 1581–7, Mosby. Brand, P. W. (1998). Mechanical factors in joint stiffness and tissue growth. J. Hand Ther., 8(2), 91–6. Clark, E. N. (1997). A preliminary investigation of the neoprene tube finger extension splint. J. Hand Ther., 10(3), 213–21. Colditz, J. C. (1995). Spring-wire extension splinting for the proximal interphalangeal joint. In Rehabilitation of the

Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 1617–29, Mosby. Cyr, L. M. and Ross, R. G. (1998). How controlled stress affects healing tissues. J. Hand Ther., 11(2), 125–30. Davey, R. B., Wallis, K. A. and Bowering, K. (1991). Adhesive contact media: an update on graft fixation and burn scar management. Burns, 17, 313–9. Fess, E. E. (1995). Principles and methods of splinting for mobilization of joints. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 1589–1598, Mosby. Fess, E. E. and McCollum, M. (1998). The influence of splinting on healing tissues. J. Hand Ther., 11(2), 157–61. Foster, A. V. M., Eaton, C., McConville, D. O. and Edmonds, M. E. (1994). Application of Opsite Film: A new and effective treatment of painful diabetic neuropathy. Diab. Med., 11, 768–772. Hardy, M. A. (1986). Preserving function in the inflamed and acutely injured hand. In Hand Rehabilitation (C. A. Moran, ed.) pp. 1–15, Churchill Livingstone. Hugo, N. (1977) General aspects and healing of skin. In Biological Aspects of Reconstructive Surgery (D. Kernahan and L. Vistness, eds) p. 339, Little, Brown and Co. Hunt, T. K. and Hussain, Z. (1992). Wound microenvironment. In Wound Healing: Biochemical and Clinical Aspects (I. K. Cohen, R. F. Diegelmann and W. J. Lindblad, eds) pp. 274– 81, W. B. Saunders. Hunter, J. M. and Mackin, E. J. (1995). Edema: Techniques of evaluation and management. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 77–85, Mosby. Katz, B. E. (1992). Silastic gel sheeting is found to be effective in scar therapy. Cosm. Derm., 1, 3. Madden, J. W. (1976). Wound healing: The biological basis of hand surgery. Clin. Plast. Surg., 3(1), 3. Madden, J. W. and Peacock, E. E. (1971). Studies on the biology of collagen during wound healing. III: Dynamic metabolism of scar collagen and remodeling of dermal wounds. Ann. Surg., 174, 511. Melzack, R. (1973). The Puzzle of Pain. Penguin Education. Neal, D. E., Whalley, P. C., Flowers, M. W. and Wilson, D. H. (1981). The effects of an adherent polyurethane film and conventional absorbent dressing in patients with small partial thickness burns. Br. J. Clin. Pract., 35, 7–8. Peacock, E. E. (1984). Wound Repair. W. B. Saunders. Smith, K. L. (1995). Wound care for the hand patient. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 237–50, Mosby. Wilton, J. C. (1997). Biomechanical principles of design, fabrication and application. In Hand Splinting: Principles of Design and Application. pp. 22–42, W. B. Saunders. Witte, C. and Witte, M. (1971). Significance of protein in edema fluid. Lymphology. 4, 29.

3 Flexor tendons

Function and anatomy
The function of tendons is to attach muscle to bone and transmit muscle action across joints. Tendons are dense connective tissues composed largely of collagen. Individual bundles of collagen are covered by endotenon. The surface of the tendon is covered by a fine fibrous outer layer called the epitenon. A thin visceral layer, the paratenon, covers the flexor tendon fascicles in the hand (Strickland, 1999). The orderly parallel arrangement of the collagen fibres equips tendons to cope with the high unidirectional tensile loads to which they are subjected during activity. While tendons are strong enough to sustain these tensile forces, they are also sufficiently flexible to curve around bone and joint surfaces and to deflect beneath the retinacular pulley system during finger flexion. Like bone, tendon remodels in response to the mechanical demands placed upon it. Collagen organization is significantly disturbed in the absence of tension. Tendon becomes stronger when subjected to increased stress and weaker when stress is reduced (Hitchcock et al., 1987). The flexor sheath and pulley system The flexor tendon sheath is composed of synovial and retinacular components. The synovial component is a tube which is sealed at both ends where its visceral and parietal layers merge (Doyle, 1989). In the index, middle and ring fingers, the synovial portion of the sheath begins at the metacarpal neck and extends as far as the DIP joint. The synovial

sheath of the little finger and thumb extends proximally to the wrist (Fig. 3.1). The synovial portion of the sheath is overlain with a series of pulleys of varying configurations, i.e. transverse, annular and cruciform. These pulleys represent the retinacular portion of the flexor sheath. The palmar aponeurosis (PA) pulley is formed from the transverse fibres of the palmar aponeurosis and was described by Manske and

Figure 3.1. The synovial component of the flexor tendon sheath. The synovial sheaths of the thumb and little finger extend proximally to the wrist. The sheath of the thumb is the radial bursa; the sheath of the little finger is the ulnar bursa.

Lesker (1983). 1980) (Fig. The close proximity of the flexor tendons to the phalanges and joints creates a short moment arm and efficient motion. The pulley system overlying the synovial component of the flexor tendon sheath represents the retinacular portion of the sheath.4). W. (a) The A2 and A4 pulleys are the most important biomechanically. are thin and pliable and collapse to facilitate full digital flexion (Fig. Pederson. In the digits there are five rigid annular (or ring-shaped) pulleys. This facilitates efficient joint motion with minimal tendon excursion via a short moment arm. results in loss of digital movement (Fig. Flexor tendons-acute injuries. blood supply is provided segmentally via the long and short vincula (Armenta and Lehrman. i. i. 3. Vascular perfusion outside the digital sheath is via mesotendineal vessels. pliable cruciate pulleys. C2 and C3. 3.e.2). with permission.e. The thumb has one oblique and two annular pulleys. A4 and A5. Synovial fluid diffusion delivers nutrients to the tendon and retinacular system via a process known as imbibition.2.3. in turn.) . They are comprised of: the palmar aponeurosis pulley (PA).3). Churchill Livingstone. Biomechanically. J. These pulleys keep the flexor tendons in close proximity to the phalanges and joints. N. (Reproduced from Strickland. Tendon nutrition Flexor tendons receive nutrition from vascular and synovial sources. the most important of the pulleys are the A2 and A4 pulleys. This is a pumping mechanism where fluid is forced into the interstices of the tendon as the digit is being flexed and extended. This process is especially important to the two avascular structures where friction and gliding take place. Figure 3. Within the digital sheath. The cruciate pulleys. Their absence results in bowstringing of the tendon and an increase in moment arm. Green. P. They also prevent the tendon from bowstringing. 3. A1. R.28 The Hand: Fundamentals of Therapy Figure 3. (b) When portions of these two pulleys are resected. A2. 1999. C. i. 1855.e. In Green’s Operative Hand Surgery (D. Hotchkiss and W. Note the bowstringing of the unrestrained tendon. These pulleys hold the tendon in close proximity to the skeleton and facilitate efficient joint motion with minimal tendon excursion. This. C1. five rigid annular pulleys and three thin. eds) p. A3. an increase in moment arm occurs and greater tendon excursion is required to move the joint through the same arc of motion.

some deterioration of tendon ends and shortening of the muscle-tendon unit becomes inevitable. Fibroblastic – this phase begins at about the fifth day and lasts for 3 to 6 weeks. Extrinsic healing is characterized by adhesions between the tendon and its surrounding tissues. 1991b). The healing process involves three distinct but overlapping phases: 1. primary tendon repair should ideally be performed The wound sustained by the injury is usually transverse or oblique and will need to be extended to allow tendon repair. Tendon repair technique Repair of the tendon is performed as atraumatically as possible. 2. however. Timing of tendon repair Although no longer considered an emergency. Intrinsic healing results in fewer and less dense adhesions. a midaxial approach is made on either side of the finger and then connected to the original laceration. The repaired sheath also serves as a barrier to the formation of extrinsic adhesions. within the first few days of injury to yield the best possible outcome (Gelberman et al. Incisions for surgical exposure the palmar aspect of the flexor tendons and the inner aspect of the pulleys. three times stronger. Four-strand core sutures are about twice as strong as two-strand methods and six-strand sutures. This suture provides significant increase in the strength of the repair and reduction of gapping between the tendon ends.. Contraindications for primary repair include: severe injury to multiple tissues. A core suture with 3–0 or 4–0 nonabsorbable thread is used. As well as providing nutrition to the retinacular system and tendon. Tendon reconstruction can be managed at a later date by two-stage tendon grafting. Alternatively. This is the collagen-producing phase during which strength increases rapidly.4. A peripheral circumferential epitendinous suture (continuous 6–0 monofilament) is used in addition to the core suture (Mashadi and Amis... Vincular blood supply of the flexor tendons. 1994). The skin laceration is usually extended to produce a zigzag approach using points and lines of minimal tension to reduce scar. a site of potential tendon adhesion is created (Potenza.Flexor tendons 29 Figure 3. For some time it was thought that the tendon itself was not involved in the healing process but rather that union could only be achieved via invasion of the healing area by paratendinous tissues. 1985). synovial fluid acts as a lubricating agent to facilitate the tendon turning a corner. Inflammatory – this phase lasts 3 to 5 days. 1992). The strength of the repair at this stage is tenuous and is imparted almost entirely by the suture. The repair continues to gain strength during this period. The tendon sheath is repaired whenever possible so that the potential for synovial fluid nutrition is restored. This phase sees a continuation of collagen synthesis and longitudinal orientation of fibroblast and collagen fibres. Biomechanical studies suggest that strength of the repair is proportional to the number of suture strands that cross the repair site (Wagner et al. has shown that the tendon does play an active role in the repair process (Lundborg et al. Wherever the tendon surface is punctured by forceps. Remodelling – this maturation phase continues for 6 to 9 months. the repair is considered somewhat vulnerable for the first three weeks after surgery. When using a twostrand method. Both flexor tendons should be repaired. wound contamination or significant skin loss over the flexor surface. 3. While delayed primary repair can be performed up to 3 weeks. Tendon healing Tendons have both an intrinsic and extrinsic ability to heal. Research. 1964). Retrieval of retracted tendon ends is achieved by proximal-to-distal milking of the tendons or with the help of a silastic cannula. The divided tendon ends are repaired as accurately as possible without tension and with the least interruption to the blood supply. .

Zone II has been called ‘no man’s land’ because of previously poor results following repair in this zone which extends from the A1 pulley to the FDS insertion and where both flexor tendons travel in the flexor sheath.5.30 The Hand: Fundamentals of Therapy Figure 3. 3. are considered capable of withstanding light unresisted active motion in the presence of full passive interphalangeal flexion (Fig. Various techniques of repairing flexor tendons. .5). (d) Becker (bevel technique). (a) Bunnell. the phrase became part of military parlance. the former execution grounds were claimed by no man. (b) modified Kessler. Zones of tendon repair Zone I is the most distal zone where only the flexor digitorum profundus (FDP) can be divided. This is the zone of lumbrical origin. Historical note The term ‘no man’s land’ originated in the Middle Ages and refers to an area outside the northern wall of London where the bodies of criminals were displayed following hanging. beheading or impaling.6.and six-strand repairs however. Zone III extends from the A1 pulley to the distal edge of the transverse carpal ligament. (c) single cross-grasp six-strand (Sandow and McMahon). Four. Injuries to this zone have Figure 3. Much later. around 1900. This served as a warning to others. When gallows were eventually built inside the city proper and the surrounding land was settled and fields were cultivated. The five zones of flexor tendon repair in the digits and three zones of repair for flexor pollicis longus. (e) Tsuge (f) six-strand using three suture pairs (Lim and Tsai). This zone is distal to flexor digitorum superficialis (FDS) insertion.

then the PIP joint and finally at all three finger joints simultaneously (Fig. Zone V covers the distal portion of the forearm extending from the musculotendinous junction to the proximal edge of the transverse carpal ligament (Fig.6).Flexor tendons 31 good results because it lies beyond the flexor sheath and restrictive adhesions are less likely. Figure 3. eds) p. Their aim has been to provide differential gliding of the FDS and FDP tendons within the constricted space of Zone II. W. Passive flexion exercises are performed individually at the DIP joint. Tendon injuries are less common in this zone due to the relative protection afforded by the transverse carpal ligament and bony architecture of the tunnel. Green. Fewer adhesions. Duran and Houser (1975) later devised a protocol which maintains the interphalangeal joints in extension. 3. The controlled passive motion method originally recommended by Duran and Houser. P. Churchill Livingstone.) . These programmes have undergone and continue to undergo modifications in response to increased knowledge of tendon nutrition and biology. Passive flexion of the interphalangeal joints pushes the tendon proximally while active or passive interphalangeal joint extension pushes the tendon distally. Gelberman and others (1980. with permission. J. N. 1999. R. In Green’s Operative Hand Surgery (D. Early application of stress following tendon repair Early application of stress to a healing tendon can biologically affect scar remodelling. 1991a) have demonstrated the following benefits associated with early passive mobilization of tendons in dogs: 1. Faster recovery of tensile strength. Improved tendon excursion. 1990. Pederson.7). The original controlled motion protocol was devised by Kleinert (1967). Zone IV is the carpal tunnel and tendon laceration in this zone can be accompanied by injury to the median and/or ulnar nerves.7. Flexor tendons-acute injuries. 3. 1866. 4. (Reproduced from Strickland. 2. Hotchkiss and W. 3. C. This involved rubber band traction which maintained the digit in a flexed posture while allowing active extension of the interphalangeal joints against the tension of the rubber band. Historical perspective of postoperative flexor tendon management A number of postoperative programmes have evolved over the past few decades. Minimal deformation at the tendon site.

. eds) p. The addition of a distal palmar pulley (which has also been incorporated into the Kleinert regimen) maintains both interphalangeal joints at almost full flexion when the hand is at rest (Fig. (b–d) The dynamic tenodesis splint. Reconstr. This splint was designed by Linwood Thomas. C. L. which is only used for the first four weeks after surgery.. for the ‘Washington regimen’.) . A combined regimen of controlled motion following flexor tendon repair in ‘no man’s land’.) Controlled active motion protocols The last decade has seen the evolution of controlled active motion protocols (Bainbridge. 3. N. 1994). Dovelle.9. J. (a) The conventional dorsal splint is worn most of the time. OTR. Plast. with permission. W. R. Figure 3. 79.. J. (Reproduced from Chow. Churchill Livingstone. et al. (Reproduced from Strickland.and six-strand repair methods together with strong peripheral epitendinous suturing have facilitated ‘place and hold’ flexion of the interphalangeal joints using Figure 3. Thomas. This has resulted in the incorporation of a distal palmar pulley (Brooke Army splint) such as that seen in the ‘Washington regimen’ described by Chow and associates (1990). P.. The introduction of four. Hotchkiss and W.32 The Hand: Fundamentals of Therapy McGrouther and Ahmed (1981) concluded that it was necessary to passively flex the joints distal to the repair in order to achieve glide of the repair site. 447–453. Surg. Green. is used on an hourly basis following passive finger flexion exercises within the static splint.8). 1987. Flexor tendons-acute injuries. The incorporation of a distal palmar pulley provides maximum passive flexion of both interphalangeal joints. 1867. Subsequent studies suggest that aftercare programmes should aim at maximum passive flexion of both interphalangeal joints. In Green’s Operative Hand Surgery (D.8. Pederson. Controlled active motion protocol used at the Indiana Hand Centre following flexor tendon repair. S. 1999. with permission.

Cannon (1993). Some surgeons believe that a two-strand repair with strong peripheral epitendinous suturing can withstand early active motion. applicable to all zones. the plaster is replaced with a thermoplastic splint which maintains the hand in the same position as the postoperative plaster. Other important factors influencing the choice of programme include: 1. 4. The type of scar produced by the patient. The level of experience of the treating therapist will also dictate treatment choice. 3. the following aims are inherent in achieving a favourable outcome: 1. 4. It is.9). Evans and Thompson (1993) and Silverskjoeld and May (1994). (1989) uses this principle.Flexor tendons 33 minimal muscle-tendon tension. Gentle passive interphalangeal joint flexion exercises are commenced on the 3rd postoperative day. Cullen et al. Splint position Following surgery the hand is placed in a dorsal plaster which maintains the wrist in neutral extension and the MCP joints in maximum flexion. . The dynamic tenodesis splint developed at the Mayo clinic by Cooney et al. (1989). The patient’s ability and/or willingness to comply with the programme. (1987). supple tissue with minimal reaction or dense. The ‘place and hold’ manoeuvre is performed with the wrist in 45 degrees of extension and maximum MCP joint flexion as this position produces the least tension on the repaired tendon (Savage. They are performed within comfortable limits and repeated on an hourly basis. Shoulder and elbow exercises are begun within a day of surgery and repeated every 1 to 2 hours. Regaining flexibility of the interphalangeal joints. however. when the inflammatory response has usually settled. 2. 3. fibrous tissue. Prevention of PIP joint flexion deformity. this usually ranging from 75 to 90 degrees.10. Exercise protocol from 3rd to 24th day On the 3rd or 4th postoperative day. Elevation of the limb is maintained. The age of the patient. (1989). The presence of associated injuries. Small et al. 3.g. damage to the neurovascular bundle or fractures. Control of postoperative oedema. Choice of treatment programme Many hand centres have developed their own programme using different aspects of one or all of the described methods. Scar management. i. Postoperative management The protocol outlined below refers specifically to repair of the flexor tendon(s) in Zone II. 1988) (Fig. Aims of therapy Regardless of which particular programme is used.10). The programme used with our patients for Zone II is outlined below and exemplifies a combined approach. The index finger can be placed behind Figure 3.e. Each surgeon has particular views and preferences and the therapy regimen will obviously be influenced by these. 2. Controlled active motion protocols have been described by Allen et al. Gentle passive interphalangeal (IP) joint flexion exercises are commenced and performed only within comfortable limits (Fig. Strickland (1993). e. 3.

It is applied more easily when the hand is removed from the splint and allowed to fall into maximum wrist flexion so that the fingers relax in extension where they will fall slightly apart.12. the elbow rested on the table and the wrist allowed to fall into maximum flexion.e. If there has been associated digital nerve repair. 30–60 s) and is followed by active intrinsic IP joint extension (Fig. It is only performed when full passive flexion has been achieved. This exercise is only performed when the IP joints can be passively flexed to full range with ease. it can be exercised by trapping the DIP joints of the unaffected fingers in extension and then gently flexing the PIP joint of the affected digit. the proximal phalanx of the involved digit while the thumb places light pressure to the fingernail so that both IP joints are flexed simultaneously. Coban wrap compression (25 mm) provides an excellent means of eliminating digital oedema.e. This is applied carefully by the therapist in a distal to proximal direction and can be done so more easily if the hand is removed from the splint. this will result in the fingers assuming a relaxed position of IP joint extension which will see the digits slightly separate (Fig. Application of a single layer of Coban (25 mm) will effectively address residual oedema. Flexion deformity of the PIP joint The combination of hourly active intrinsic IP joint extension exercises and Coban is usually sufficient . Note: If a controlled active motion protocol has been requested.12). however. Active movement of flexor digitorum superficialis (FDS) If FDS is intact. This manoeuvre is performed two Figure 3. to three times every 4 h during these first 31 weeks 2 and is held for 1 to 2 seconds only with minimal effort. This helps maintain glide of the uninjured FDS tendon. the exercises are carried out with even greater care as hypersensitivity at the repair site is common.11). Resolution of digital oedema Digital swelling often subsides significantly following the commencement of the exercise routine. 3. full IP joint extension. Under ideal circumstances. Both passive flexion and active intrinsic extension are usually limited at this early stage by digital oedema and discomfort. when performed on an hourly basis with 5 to 10 repetitions. Each passive flexion manoeuvre is held for a short period (i. Active intrinsic interphalangeal joint extension exercises are also repeated on an hourly basis.34 The Hand: Fundamentals of Therapy Figure 3. full passive IP joint flexion and full active IP joint extension should be achieved by the end of the second postoperative week. i. The patient should aim to extend to the limit of the splint. This is often not possible during the first few days due to oedema and wound discomfort.11. 3. the author uses the ‘tenodesis manoeuvre’ described in the ‘Day 24 to end of week 6’ section. improvement is usually seen quite rapidly within the first few days. One layer of Coban applied under negligible tension is sufficient. Sutures are removed at this time.

Nylon thread is then attached to holes punched through the sides of the sling. the warmth of the water will make passive flexion exercises easier. covering the area with Opsite Flexifix will often reduce hyperaesthesia significantly. Prior to the commencement of active exercise. The newly repaired tendon must not. when the patient is performing the massage. however. a soft ‘sling’ is placed on the volar aspect of the middle phalanx. this modality can be used alone. . From their flexed position. If hypersensitivity is problematic enough to interfere with the exercise programme. the sling is used during sleep. Massage can be performed out of the splint by the therapist. the patient is asked to actively extend the IP joints to their maximum range as they have been doing in the to prevent the development of a PIP joint flexion deformity. the fingers can be gently bandaged into flexion prior to immersion in the water. This is referred to as ‘drag’. With the wrist in neutral and the MCP joints supported in 20 to 30 degrees of flexion. Where raised. As a tendon glides. the hand is bathed in warm soapy water to cleanse the skin. Also. Where a deformity has developed. The nylon is then threaded through a hole made in the splint and attached to a hook on the outside of the splint. The sling is removed for hourly passive IP joint flexion exercises and intrinsic IP joint extension exercises (Fig. If Coban wrap is not already being used for swelling control. sutures and healing scar. This more extended MCP joint position will help accommodate extrinsic finger flexion. silicone gel is used under the Coban during the night and intermittently throughout the day. Every 2 h the hand is removed from the splint and rested comfortably on the table in neutral wrist extension. it is safer to keep the hand within the splint and undo the distal splint strap if necessary. The tension applied by the sling should be negligible and the line of pull should be at right angles to the middle phalanx. the sling is removed hourly to perform passive IP joint flexion exercises. Patients who heal with dense scarring often have an increased propensity toward PIP flexion deformity. dense scar restricts passive flexion or is painful to touch. Active flexion is only begun if the patient is able to passively flex both IP joints to near-normal flexion range with ease. Following injury and surgery.13). the patient must first ‘warm up’ with passive flexion exercises. This will necessitate the wrist being brought into neutral extension while the fingers are passively held in the flexed position. it can be addressed with a small thermoplastic splint that is applied to the dorsum of the joint in a position of slight correction. The latter is especially important where the digital nerve repair has also been performed. Gentle oil massage is performed to soften the scar and to begin the desensitization process. Where necessary. 3. Scar management Following suture removal. This can be managed with a sling that applies negligible extension force to the digit. this is gradually modified until full correction has been achieved. Unless scar is particularly dense. this resistance is significantly increased due to swelling. The last few degrees of passive flexion can sometimes be restricted by dense scarring or residual oedema. If passive IP joint flexion range is still restricted.Flexor tendons 35 Figure 3.13. it meets a certain degree of normal resistance from surrounding tissues. it should be added to the programme for its effectiveness in providing gentle compression to scar. During the day. Finger pressure should be very light during the first few sessions until increased pressure can be tolerated. Alternatively. the wrist should be passively held in maximum flexion range. be subjected to the added stress of overcoming joint stiffness when active movement is commenced. Day 24 to end of week 6 At 31 weeks gentle active flexion exercises are 2 begun. the MCP joints are actively extended to within 20 or 30 degrees of full extension and gently supported. therefore. To protect the tendon repair.

This position is held for 3 to 5 seconds. (b) Figure 3. When maximum IP joint extension range is reached. From the 4th week onward. These patients are protected for a longer period. Patients who demonstrate marked active flexion range are considered at greater risk of rupture due to minimal scar formation. the patient should be shown ‘place and hold’ exercises as it takes less force to maintain an already flexed finger in the flexed position than it does to actively bring the finger into flexion from the extended position. (a) splint. This position is gently held for several seconds before the exercise is repeated.36 The Hand: Fundamentals of Therapy Tenodesis manoeuvre If active flexion range is minimal or where the risk of rupture is considered greater. it can be done so with the lessstressful tenodesis manoeuvre described below. (a) The first part of the ‘tenodesis manoeuvre’ involves passively flexing the fingers and allowing the wrist to assume a position of 45 degrees extension. Five to ten repetitions are performed.14. allowing the wrist to extend to 40 to 45 degrees and then removing the passive support and asking the patient to maintain the flexed finger position with minimal active muscle-tendon tension (Fig. Patients who demonstrate significant active range with ease are ‘held back’ because they tend to be at greater risk of rupture due to minimal scar formation. (b) The wrist is then brought forward into flexion while the fingers gently extend. The wrist is then brought Figure 3. Gentle combined active IP joint flexion (i. . the patient is then asked to actively flex both IP joints simultaneously with minimal effort (Fig. This means that the commencement of active movement is delayed by another week and protective splinting is continued for 1 to 2 weeks longer. 3. Savage (1988) has shown that this position produces the least tension on the repaired tendon during active movement.e. both IP joints simultaneously) is practised second-hourly with 5–10 repetitions at each session. Active range of motion is usually still quite limited at this early stage. 3. These early attempts may yield 30 or 40 degrees of PIP joint flexion and 20 or 30 degrees DIP flexion. This manoeuvre involves passively flexing the fingers.15.15(a)). the MCP joints can be increasingly extended during IP joint flexion exercises to better facilitate flexor tendon pull-through. Passive support is then removed and the patient is asked to maintain the flexed position with minimal active muscle-tendon tension. When active movement is then initiated.14). Resisted use of the hand will also be delayed by several weeks.

The patient may find it helpful to perform their active exercises in both of the described ways.18). Bradflex).17). This manoeuvre is repeated 5 to 10 times second hourly (Fig. 3. Week 8 onwards Gentle resistance is added to active flexion exercises and activity can be upgraded. This can be addressed with serial volar splints which exert a gentle corrective extension force and are worn at night and intermittently throughout the day.Flexor tendons 37 forward into flexion while the fingers gently extend. however. The light (sustained) squeezing of a soft bath sponge in warm water is a suitable exercise at this stage. they need not be Figure 3. Weeks 6 to 8 The splint is discarded at the end of the 6th postoperative week unless the nature of the scar indicates that extended protection is necessary. the injured finger can be buddytaped to an adjacent finger with Microfoam tape if limitation of active flexion range makes gripping objects difficult. 3. If adhesions are affecting tendon glide. Light-grade exercise putty is added to the programme by the 7th week. Repair in Zones III.18. Small handles such as cutlery or razor can be temporarily built up with insulation tubing (i.15(b)).e. Light-grade exercise putty can be added to the programme by the 7th week. the tension applied should be low and the correction should be gradual to avoid rupturing the repair. Putty squeezing should be carried out in a slow and sustained manner and the patient should take care not to over-exercise. Occasionally soft tissue tightness is quite marked. Three or four short sessions (5 min) each day are sufficient as the patient should also be engaging the hand in regular activity (Fig. An MCP joint blocking splint will facilitate pull-through of the extrinsic flexor tendons. Regardless of the splinting method used. the use of an MCP joint blocking splint will facilitate pullthrough of the extrinsic flexors (Fig. The hand can be used for light daily functional activities that are minimally resistive. The patient should feel a gentle stretching sensation that is not painful.e. This may warrant the use of a dynamic outrigger. During activity. Figure 3.17. IV and V is often accompanied by tethering of the tendon to skin and surrounding tissues and some shortening of the muscle-tendon unit. . Residual flexion deformity of the PIP joint is addressed with a neoprene fingerstall (Fig. Patients whose work does not involve heavy manual activity usually return to work at this stage. Figure 3. Unresolved flexion deformities of the PIP joint are managed with a neoprene fingerstall from the 6th week onward.16). 3.16. 3. Stabilized exercises are continued. the tenodesis effect. i.

Postoperative splint used following repair of flexor pollicis longus. Some patients find it difficult to isolate FPL function and tend to overuse the intrinsic thenar muscles when active exercises are begun. . To avoid compensatory movements by the intrinsic thumb muscles during IP joint flexion exercises. A tenolysis procedure aims to free the tendon from its adhesions and restore its glide. Final range of active motion may not be achieved for some months following cessation of formal therapy. Technique The procedure is performed under local anaesthetic using a zig-zag incision. Note: Many patients make steady gains in active flexion range during the first 3 to 4 postoperative months. This period is extended for a further 2 weeks where scar formation has been minimal. The thumb is held in slight palmar abduction with the MCP in 30 degrees of flexion and the IP joint in neutral extension. with the wrist in neutral or very slight flexion.38 The Hand: Fundamentals of Therapy repeated as frequently. i. the patient is awake and able to participate so that the surgeon is able to carry out just enough dissection and freeing. Secondary joint changes (capsule or ligament fibrosis) may also need correction. 1996). Figure 3. Patients whose work is heavily resistive do not return to work in their normal capacity until the end of the 12th week.e.. The tip of the thumb should be in line with the middle finger (Fig. By using this type of anaesthesia. skin. retinacular ligament and bone. have failed to restore a functional range of movement (Fetrow. Return of function is more of a priority at this stage in rehabilitation and patients are encouraged to perform domestic or mechanical tasks as part of their therapy programme if they have not yet returned to work.19). 1967 and Baker et al.19. Flexor pollicis longus (FPL) repair Splint position The splint is applied to the dorsum of the forearm and hand. Tenolysis Any injury or operation that interferes with the smooth gliding surface of the tendon system predisposes the tendon to becoming adherent to adjacent tissues. This can be applied between the 4th and 5th week (Fig. Patients are advised that twostage tendon reconstruction may be necessary if the tendon motor and/or flexor pulley system prove inadequate. Patients who heal with dense scar frequently show slower progress. 3. used over a period of at least 3 to 6 months following injury or surgery. 3. Figure 3.20. This tendency can be overcome with an MCP blocking splint which will restrict movement to the long thumb flexor. Tenolysis is indicated only when comprehensive therapy measures. Exercise protocol The exercise protocol is the same as for repair of a digital flexor tendon. Patient selection is most important as strong motivation and full co-operation are required in the postoperative phase.20). a blocking splint is used to isolate the action of flexor pollicis longus. Patients are therefore encouraged to persevere with their exercise/activity programme.

intrinsic plus position. The exercises are repeated 3 to 4 times on the first day and hourly thereafter. i. i. ‘place and hold’ exercises are replaced with gentle unstabilized composite flexion exercises from a position of digital extension. Discussion with the attending surgeon is therefore essential. i. Tendons deemed to be in good condition can be exercised more vigorously. before adhesions have an opportunity to become re-established. Oedema and pain control The hand is maintained in elevation between exercise sessions and ice packs are used every 3 to 4 hours prior to exercise during the first 2 to 3 days to reduce swelling and discomfort.e. This position of passive flexion is held for a short period (i.Flexor tendons 39 Postoperative management The immediate postoperative exercise regimen will vary from patient to patient and will be determined by the integrity of the freed tendon. The aim of therapy is to reproduce the range of movement that was achieved during surgery. elbow and forearm. the IP joints are flexed while the MCP joints are maintained in extension. i. Coban wrap can be applied over the dressing to help control swelling. the fist can be ‘flat’. Stabilized exercise for ‘at risk’ tendons is delayed until the 3rd postoperative week. A hook grip is made. Splints that block the MCP joints in extension and provide more effective pullthrough of the flexor tendon can be used by the end of the 2nd week. The first postoperative week is the most important (Schneider and Berger-Feldscher. only ‘place and hold’ exercises are performed during the first week as they require less tensile loading. 1995). For more vulnerable tendons. Composite flexion involves simultaneous flexion of all three finger joints. . the fingers are exercised in a variety of ways: 1. with the DIP joints flexed.e. Optimizing tendon glide To promote optimal tendon glide.e. Exercise protocol (days 0 to 7) Where the tendon is deemed to be at risk of rupture.e. To provide further differentiation. Days 7 to 14 Stabilized (or blocking) exercises are added to the active exercise programme for ‘low risk’ tendons. i. The exercise regimen should be sufficient to promote maximum tendon glide without causing an inflammatory response or increasing oedema. or ‘tucked’. 30–60 s) after which time the supporting hand is removed and the patient is asked to maintain the position with minimal active muscle-tendon tension for several seconds. 3. The digits are then gently extended (actively) and the manoeuvre is repeated another 3 to 5 times. MCP joints are flexed with the IP joints held in extension. Response to exercise is monitored on an individual basis and the programme is modified accordingly. MCP joints in flexion and the IP joints in extension.e. Splint The hand can be rested in the position of safe immobilization. The exercise session is repeated every 3 to 4 hours during the first day and on an hourly basis from then on. They should be preceded by passive exercises so that the tendon does not have to overcome the resistance of stiffened joints. gentle active unstabilized finger exercises are begun.e. Care is taken to keep the wound dry and sterile. Appropriate pain relief should be provided prior to active exercise which is commenced on the day of surgery. The fingers are passively flexed to a comfortable range by the therapist or the patient’s uninvolved hand. Where tendon integrity is considered sound. The immediate postoperative dressing may require de-bulking to ensure effectiveness of the ice pack and to facilitate exercise. with the DIP joints in extension while the MCP and PIP joints are flexed. 2. A single layer is sufficient and should not interfere with exercise. Poor quality tendons have a greater risk of rupture and should be exercised with some caution. Wrist movements are also practised at each exercise session together with movements of the shoulder. wrist comfortable extension. Each session should see a slight increase in flexion range.

. Soft supple tissues. 3. Over-vigorous Two-stage tendon reconstruction Where tendon glide has been compromised by injury and/or surgery and tenolysis has been unsuccessful. tendon function can be restored with a two-stage procedure (Hunter et al. Gentle passive IP joint flexion and active IP extension exercises are begun. First stage of flexor tendon grafting. It is then threaded along the digit and through the carpal tunnel to lie freely proximal to the wrist. To encourage use of the hand in suitable light activity. 2. Annular pulleys are reconstructed over the implant around which a fibrous pseudosheath forms during the next 8 to 10 weeks (Fig. 1995). Silicone gel can be used beneath Coban or a silicone-lined finger sleeve can be worn. The muscle motor is anchored to the adjacent muscle-tendon unit if FDP is involved or to the flexor retinaculum if FPL is involved. 2. proximal to the wrist. Postoperative management Days 1 to 14 For the first 2 weeks the hand is rested on a volar splint with the wrist in slight extension or neutral and the fingers close to neutral extension. To maintain mobility of all upper limb joints. Resisted exercise and activity can commence at week 6 and full resistance can be tolerated after the 8th week. Patient selection for two-stage tendon reconstruction is even more important than for tenolysis because it requires two surgical procedures and a personal and economic commitment to a protracted aftercare programme. nerve repair/graft or capsulotomy to improve joint range of motion. Stage 1 The scarred tendon is resected and replaced with a silastic implant or ‘rod’. No passive IP joint flexion exercises or active wrist movements are performed during this time. Day 14 onwards The sutures are removed and massage to scar is commenced.21). 4. Light gripping activities can be commenced at this time. Figure 3. This first stage may also involve scar correction. To soften scar tissue and restore soft tissue mobility in preparation for the second stage.40 The Hand: Fundamentals of Therapy Sutures are removed around the 14th day and oil massage and scar management are begun.21. Adjacent finger joints can be gently exercised. 3. These exercises are to be performed slowly and carefully and within the limits of pain. The implant (silastic rod) is attached to the distal tendon stump and then threaded along the digit and through the carpal tunnel to lie freely. . The purpose of rest is to safeguard against silicone synovitis which has been associated with early postoperative exercise. Preoperative requirements 1. Gentle active wrist movement is also carried out. Postoperative aims 1. The implant is attached to the distal tendon stump. active exercise and light activity are continued. 3. Day 14 onwards Scar management. Full or near-normal passive flexion of the IP joints. To regain passive flexion and active extension range. Oedema is managed with elevation and ice packs. Full or near-normal digital extension.

C. 1. It is then pulled through the new tendon bed. B. 517–21. Silicone gel is used over palmar scar. M. Hand Surg. Ruptured flexor tendon tenorrhaphies in Zone II: repair and rehabilitation. References Allen. (1980). D.. and Wood. At the distal juncture. 12A. Stage 2 The second stage of reconstruction is usually performed 8 weeks after the first and involves removal of the implant and a tendon graft. Cannon N. J. the tendon is drawn into the bone with monofilament stainless steel or a nonabsorbable suture. A. Early signs of synovitis can include: 1. N. If the patient has difficulty in regaining flexion range. Hand Surg. K.. Scar is managed with a silicone-lined fingerstall which is worn throughout the night and intermittently during the day.. i. The proximal end of the graft is attached to the motor tendon with a Pulvertaft end-weave technique. Hand Surg. 127–34. To maintain interphalangeal joint flexibility of the affected digit. Baker. Swelling over the proximal end of the implant. E.e. S. Flexor tenolysis: a worthwhile procedure in a select patient population. 131–40. The wire is tied over a button on the dorsum of the fingernail. Incisions are made over the distal and proximal juncture sites. flexible and reusable.22. 3. Bainbridge. 5. Because the grafted tendon has a more precarious blood supply. Gillies. A. S. 1. and Eakins. M. Sudden increased swelling along the volar aspect of the finger. K. it is ‘buddy-strapped’ to an adjacent digit during light activity. (1996). (1993). For this reason. Normal residual digital oedema is treated with a single layer of Coban wrap.23). The patient is not permitted to engage the hand in heavy activity while the implant is present. G. Unsell. D. 19B. 2. 4. Robertson. and Lehrman. only the gentlest of pressure is used during these manoeuvres. and Elliot. E. To encourage flexibility of the affected digit. it is buddy-strapped to an adjacent digit during light activity and exercise (Fig. Post flexor tendon repair motion protocol. A comparison of postoperative mobilization of flexor tendon repairs with ‘passive flexion-active extension’ and ‘controlled active motion techniques’. there is increased risk of rupture. 3. Short sessions (1–2 min duration) every 2 h are sufficient during the first week of exercise..22). V.. J. Tonkin.. P.. 13.. Microfoam tape makes an effective buddy-strap as it is soft. Figure 3. at the wrist. The vincula of the flexor tendons of the hand. 18–21. The tendon graft (palmaris longus. F. this remains in place for a minimum of 6 weeks.. J.Flexor tendons 41 exercise can easily result in synovitis. Indiana Hand Center Newsletter. (1987). Figure 3. Loss of passive range. plantaris or a long toe extensor) is harvested and sutured to the proximal end of the implant. D. D. the various therapy milestones are delayed by 1 to 2 weeks. Note use of silicone gel to soften the wrist scar. however. (1994). Frykman. the hand is bandaged gently into flexion several times a day or a digital flexion strap is used. The aftercare regimen following the second stage of reconstruction is as for primary repair. . R. Armenta. Hand Surg. J. 3.23. the various therapy ‘milestones’ are all delayed by approximately one week (Fig. Postoperative management The aftercare regimen is as for primary repair with the proviso that the programme is carried out more cautiously. Pain at rest or during passive flexion.. Dunn.

Gelberman. Biologic rationale. (1996). In Rehabilitation of the Hand: Surgery and Therapy. J. (1994).. J. (1989). J. Rank. and van Strien. 15A. J. B. Pruitt. Gelberman.. (J. and Morrison. The influence of wrist position on the minimum force required for active movement of the interphalangeal joints..42 The Hand: Fundamentals of Therapy Savage. Hand Ther.. 10. A. D.. N. 477–514. L. K. Primary repair of lacerated flexor tendons in ‘no-man’s land’ (abstract).. Bone Joint Surg. A clinical evaluation of two hundred and twenty flexor and extensor tenolyses. Khabie.. 17B(2).. (1991b). Cullen. P. 113–7. D.. Strength of the suture in the epitenon and within the tendon fibres: development of stronger peripheral suture technique. Flexor tendon excursions in ‘no man’s land. Healing of digital flexor tendons: importance of the interval from injury to repair. Mosby. 73A(1). Watson. L. S. Silverskjoeld. 19. Nutritional aspects of tendon healing. A new approach to flexor tendon repair. C. Mackin and A. Mosby. Stephens. H. Strickland. J. E.. O. In Rehabilitation of the Hand: Surgery and Therapy (J.. Hand Surg. E.. E. M. A. Surg. and Berger-Feldscher. 153.. C. Doyle. Hand Ther. K. D. E. M. and results of early motion following flexor tendon repair. North Am.. Pederson. A. C. S.. D. 1851–97. (1980). M. Chow. J. Woo. 19A. E. Biomechanical and histological characteristics of canine flexor repair using early postoperative mobilization. Mosby. J. M. (1964). and Martinez. Callan. C.. 262–8. (1993). O. 577. Flexor tendons-acute injuries. J.. A. R. J.. D. E. Ngai. 1. Amiel. F. T. 105–14. 53–60. J. H. and May.. et al. K. (J. Manske. Strickland. W. et al. J. 1. Carroll. W. 66.. H. R. (1989). et al. Bone Joint Surg. 61. L. 69–77. Intrinsic tendon healing: a new experimental model.H. Clin. W.. Schneider. 12A. B. The application of force to the healing tendon. Ashbell.. M. (1992).. P. Lin. 41. M. (1995). M. J.. A. R. Callahan. and Manske. 93–109. H. mechanical testing and preliminary clinical results. 102–6. S. W. Peck.. M. J. Hitchcock. (1995). Siegel. S. H. D. Hand Clin. May. D. eds) pp.. Cooney. 433–62. T. Mackin. Hand Surg.. F. J. D. Flexor tendon repair in zone II followed by controlled active mobilization. . J. Design. J. Taras. E. H. B. J. J.. et al. Menon. 8. M.. 187. P. Callahan. The effect of immediate constrained digital motion on the strength of flexor tendon repairs in chickens. J.. (1989). Tenolysis in the hand and wrist. Hand Surg. Potenza. and Sollerman. J. W. W. Mosby. 164–7. and Hunter. W. M.. 17A. 172. Early active mobilization following flexor tendon repair in zone 2. (1999). 71–8. (1989). H.. 266–84. Z.. Callahan. S. F. J. Stewart. and Roe.. J. L.. M. and Page. W. (1983). Amadio.. Plast. Y. The revascularization of healing flexor tendons in the digital sheath: a vascular injection study in dogs. 409–16. G.. Staged flexor tendon reconstruction using passive and active tendon implants. 942–52. A. 513–6. Hotchkiss and W. S.. A. 283–89. Controlled passive motion following flexor tendon repair in zones II and III. 129. G. 383–91. Postoperative management of flexor tendon injuries. 463–75. Influences of flexor sheath continuity and early motion on tendon healing in dogs. et al. J. J. Complications of flexor tendon injuries. Bone Joint Surg. 22A. P. (1990). 6.. 306–8. 73A. J. Taras. E. R. 349–51. J. C. E. M. J. Evans. P. Callahan. J. Mackin and A. 19B. (1981). Mackin and A. and Thompson. (1985). Orthop. and Amis. Surg.. (1994). H. Gelberman. Scand. An audit of flexor tendon injuries in zone II and its influence on management. Hand Surg. Hand Surg. pp. Light... V. Lundborg. W. J. A biomechanical comparison of techniques of flexor tendon repair. F. D. J. Hand. J.. R. Flexor tendon injuries. J. Strickland. 15A. (1989). R. E. (1995). J. R. 14B. Tendon gliding exercises. Hand Surg.. Flexor tendon repair in zone II with a new suture technique and an early mobilization program combining passive and active motion. Mashadi. and An. eds) pp. Churchill Livingstone. 645–51. In Green’s Operative Hand Surgery (D. 13B. G.. G. K. T. 19A. E.. In Rehabilitation of the Hand: Surgery and Therapy. Kubota. Jaeger. Hunter. (1994). Hunter. Fetrow. Hand Surg. J. and Colville. R. D.. J. D. Clin. (1967). J. P.. R. Kleinert. In AAOS Symposium on Tendon Surgery of the Hand. L. L.. Hand Surg. eds) pp. 868–81. T. J. (1994). S. 590–5. Hand Surg. Mackin and A. 2. Tenolysis: Dynamic approach to surgery and therapy. Hunter. Gonsalves. Brennen. P. M. 259–63. Flexor tendon repair: Indiana method. R. 14B. 49A. eds) pp. S. Ther.. J. Silverskjoeld. A. 2. T. W. and Lesker. Gelberman. H. Hand Surg. H.. J. J. J. (1995). Green. A. P. H. Hand Ther. Indiana Hand Center Newsletter. Tolhurst. Reconstr. (1991a). and Cahill. (1997). Hand Surg. E. Further reading Aoki. Bucher. (1993). M. Occup.. Kleinert. clinical application. Savio. (1988). Wagner. Mosby. T.. 187–91. Wehbe. Hand Surg. In Rehabilitation of the Hand: Surgery and Therapy (J. R. Prevention of adhesions to healing digital flexor tendons. eds) pp. and Culp. Bone Joint Surg. and Akeson. R. 267–86. 667–85. Strickland. A. W. Duran.. (1990). K. Hand Surg. 9. M. (1981). Bunch. P. Improved tendon excursion following flexor tendon repair. Gray. (1975). and Houser. D. Controlled mobilization after flexor tendon repair in zone II: a prospective comparison of three methods. 13. J. Hunter. 392–5. 49A. The effects of mobilization on the vascularization of healing flexor tendons in dogs.. R. R. A splint for controlled active motion after flexor tendon repair. M. J. Kutz. Lang. S. (1992).. et al.. Hand Surg. 979–83. J. W. C. Schepels. Palmar aponeurosis pulley. Anatomy of the flexor tendon sheath and pulley system: a current review. J. B. Hand Surg. J. E. P. (1987). Small. and Gill. E. K. K. 107–14.. A. Am. R. 14A.. R. J... and Heinau. J. (1987). McGrouther. and Ahmed. Hunter. J..

g. however. juncturae tendini and the extensor tendon. the extensor mechanism in the hand and fingers is covered by paratenon. can be treated conservatively with splinting (Fig.4 Extensor tendons The dorsum of the hand has minimal subcutaneous tissue.1). 4. extensor carpi ulnaris. These six . 4. many extensor tendon injuries. juncturae tendini). At this level the tendons are surrounded by a synovial sheath and held in place by five fibroosseous tunnels (or compartments) and one fibrous tunnel. The extrinsic extensor digitorum communis (radial nerve). fibrous structure combining fibres from the sagittal band. 2. the communis tendons are joined by fibrous interconnections known as juncturae tendini. Extensor tendon injuries are generally regarded as less significant than those involving flexor tendons. extensor pollicis longus. Postinjury complications. the function of which is to prevent bowstringing of the tendons. Anatomy The extensor mechanism is characterized by numerous soft tissue attachments and interconnections (e. The soft tissue attachments and the support of the paratenon ensure that retraction of the divided tendon is limited. 3. Dorsal hood of MCP joint The dorsal hood of the finger MCP joints is a broad. Over the dorsum of the wrist. extensor digiti minimi and the sixth.2): 1. are common and can include tendon adhesion. The lumbrical muscles (ulnar and median nerves). The intrinsic volar and dorsal interossei (ulnar nerve). Dorsal compartments The first compartment houses abductor pollicis longus and extensor pollicis brevis. extensor digitorum communis (EDC) and extensor indicis proprius. (the fifth dorsal compartment). Inadequate management can result in significant functional loss. The tendons in this region are broad and flat with a significant tendon-bone interface. Just proximal to the MCP joints. As a result. the extensor retinaculum. extensor lag and stiffness. the primary extensor of the MCP joints. the third. the extensor tendons are considerably more substantial and are overlain by a wide fibrous band. compartments are separated by septa that arise from the retinaculum and insert onto the radius. particularly those over the digits. It serves to centre the EDC tendon. the fifth. Extensor mechanism of the digit The extensor mechanism of the digit is a conjoint tendinous structure that is formed by the merging of the following structures (Fig. the second. Unlike the flexor tendons which are surrounded by a synovial sheath. This means that extensor tendons are vulnerable to injury due to their relatively superficial location. the fourth. extensor carpi radialis longus and extensor carpi radialis brevis.

2. Hotchkiss and W. Churchill Livingstone. with permission. J. Churchill Livingstone. P. The extensor mechanism of the digits. It prevents dorsal dislocation and bowstringing of the lateral bands during IP joint extension and serves to stabilize the extensor tendon over the PIP joint in the way that the sagittal band does at the MCP joint. eds) p. They contribute to IP joint extension only when the MCP joints are simultaneously flexed. N. 1951. R. Elizabeth Roselius. R. (Copyright.44 The Hand: Fundamentals of Therapy Figure 4. Extensor tendons-acute injuries. The extensor mechanism of the hand depicting the extensor tendons. Extensor digitorum communis Distal to the MCP joint. The lumbricals are the prime intrinsic interphalangeal joint extensors. Intrinsic volar and dorsal interossei The dorsal and volar interossei are separated from the lumbricals by the deep transverse metacarpal ligament. Green. Pederson. 1999. Pederson. The lumbricals The lumbricals are unique in that they are the only muscles that arise from a flexor tendon and insert onto an extensor tendon. The interossei are the primary MCP joint flexors. 2. the six dorsal compartments and the synovial sheaths. Elizabeth Roselius. 1999. (Copyright. 1953. the extensor tendon trifurcates into a central slip and two lateral slips. Hotchkiss and W. Oblique retinacular ligament (ORL) The ORL passes from the flexor sheath of the proximal phalanx and joins the lateral margin of 1. eds) p. Extensor tendons-acute injuries. 2. Reproduced from Doyle. P. R. Transverse retinacular ligament This ligament arises from the flexor sheath and volar plate at the PIP joint and passes to the lateral border of the conjoined lateral band. C.) Figure 4. with permission. C. Reproduced from Doyle.) 3. Retinacular ligaments 1. The two lateral slips of the extensor tendon pass on either side of the PIP joint and join with the lateral bands of the intrinsic muscles to form the conjoined lateral bands. . the extensor retinaculum. These unite distally as the terminal tendon and insert into the distal phalanx. the juncturae tendini. The central slip inserts into the base of the middle phalanx where it is joined by a medial band of oblique fibres from the lumbricals and interossei. Green. N. In Green’s Operative Hand Surgery (D. R.1. They arise from the tendon of flexor digitorum profundus and insert onto the radial lateral band of each finger. In Green’s Operative Hand Surgery (D. J.

The horizontal mattress suture is weaker than the weave sutures but is suitable for broad. 4. I II III IV V VI TI T II T III T IV TV VII Zones of extensor tendon injury The location of an extensor tendon injury will influence the type of treatment.3). 3. Triangular ligament This ligament consists of a fascial layer between the conjoined lateral bands and the terminal tendon distal to the insertion of the central slip onto the middle phalanx. It helps co-ordinate uniform flexion and extension of the PIP and DIP joints. extensor mechanism becomes increasingly thin in its distal zones. The ORL is considered to be a retaining ligament that centralizes the tendon on the dorsum of the finger (Harris and Rutledge. with additional skin coverage where required. Specific treatment regimens are discussed in each zone. (1995) concluded that the Kleinert modification of the Bunnell suture and the modified Kessler technique provided the greatest strength and were able to tolerate controlled active motion protocols. A ninth zone has now been added to the classification. This should be by either a local or distant flap as skin grafts should not be applied over tendons (Fig. Zones of extensor tendon injury in the digits and thumb. A delayed primary procedure is then performed under optimal conditions. Closed injuries Closed injuries are best managed by splinting. it should be debrided until satisfactory healing has occurred. It will also determine the deformity and functional impairment. The original classification by Kleinert and Verdan (1983) included eight zones in the digital extensor mechanism and five zones for the thumb. primary extensor tendon repair is indicated as soon as possible after injury. This ligament prevents excessive volar subluxation of the conjoined lateral bands on flexion of the PIP joint. .3. Its course is volar to the axis of the PIP joint but dorsal to the axis of the DIP joint. The extensor mechanism can be injured from the fingertip (Zone I) to the middle or proximal forearm (Zone IX). The suture technique is modified according to the site of repair as the VIII IX Figure 4. If the wound is dirty or contaminated. 4. flat tendons with longitudinal fibres. soft tissue cover takes priority over tendon reconstruction. 1972). This urgency is not as great as for flexor tendons because in Zones I to V the retinacular fibres and juncturae between the tendons prevent significant retraction of the proximal tendon end.4). Surgery for open injuries In the case of a tidy wound. it covers the muscular area over the middle and proximal forearm (Fig. In complex injuries involving loss of substance (particularly in Zone VI) or where there are fractures and joint injuries.Extensor tendons 45 the terminal extensor tendon. A study by Newport et al.

The horizontal mattress suture is suitable for broad. These injuries are frequently associated with a small avulsion fracture at the base of the distal phalanx where the tendon inserts (Fig. Correct positioning within the splint is best maintained with taping rather than strapping (Fig. It is our experience that patients involved in this protocol also benefit psychologically from early active participation.4. Evans and Burkhalter (1986) reported their 6-year experience using controlled motion in the treatment of untidy extensor injuries. 1975 and Gelberman et al.. Zones I and II Interruption of the extensor mechanism over the DIP joint and the distal portion of the middle phalanx results in a flexion deformity of the joint. 1970). The introduction of controlled mobilization techniques in the management of extensor tendon injuries has led to improved results.6). Because of the propensity toward tendon adhesion. Technique for extensor tendon repair. Elliot and McGrouther (1986) and Brand and Hollister (1993). 60 degrees of IP joint flexion effected 5 mm of tendon excursion at Lister’s tubercle with the wrist in neutral and the thumb MCP joint in extension. Conservative management of closed injury Closed injuries are treated with a dorsal or volar splint which maintains the DIP joint in extension for a period of 6 to 8 weeks. 1986) is sufficient to promote glide and stimulate cellular activity without causing gapping or rupture of the repair. most patients being managed with the controlled mobilization protocol are nearing the end of formal therapy. (1990) and Saldana et al. . early controlled mobilization Repaired extensor tendons have traditionally been immobilized for a period of 3 to 4 weeks prior to the commencement of active movement. While the first few treatments are labour-intensive and timeconsuming in terms of splint fabrication and patient education. treatment results were frequently disappointing. particularly in the more challenging Zone III over the PIP joint. (1991). Evans and Burkhalter (1986) determined that 30 to 40 degrees of MCP joint motion effected 5 mm of extensor glide in Zones III. V.5). the rate of progress and overall result far outweigh these initial commitments. It has been suggested that 3–5 mm of tendon excursion (Duran and Houser. 4. a mallet finger. The treatment programmes described below will include conservative management of closed injuries together with static and controlled mobilization protocols following surgical repair of extensor tendons. Where patients being treated with immobilization are just commencing their active therapy programme at week 4. In the case of extensor pollicis (EPL) repair.e.46 The Hand: Fundamentals of Therapy Figure 4. Hung et al. The controlled passive and/or active mobilization protocol is only used with patients who are able to comply with the regimen. The position of the DIP joint in the splint needs to be critically evaluated as even slight flexion at the joint will cause attenuation of the tendon callus and a resultant extensor lag. IV. Postoperative management: immobilization vs. i. VI and VII. flat tendons with longitudinal fibres. 4. Their treatment protocol was developed using knowledge of extensor tendon excursion as reported by Bunnell (from Boyes. The injury can be either closed or open. Discussion between surgeon and therapist is essential in determining the protocol most suitable for each patient. The effectiveness of early dynamic splinting has been verified by Browne and Ribik (1989).

Types of mallet finger injury: (a) rupture of distal extensor tendon.6. (c) fracture separation of epiphysis of distal phalanx. an additional 3 to 4 weeks. extension splinting is reinstituted for a further 2 weeks when the situation is reassessed. If the distal joint is swollen. A layer of paper tape (e. The goal is then to achieve a further 10 degrees during each ensuing week. A closed mallet finger injury is treated with 6 weeks of immobilization.5. Patients who demonstrate significant flexion range when the splint is removed tend to be more prone to a recurrence of the deformity. the PIP joint has assumed a posture of hyperextension in association with the flexion deformity at the DIP joint). Coban used beneath the splint will hasten resolution of oedema. Figure 4. Following the immobilization period. The PIP joint is placed in 35 to 45 degrees of flexion to advance the lateral bands. The patient must ensure that the DIP joint is supported in full extension whenever the splint is removed. The patient attempts gentle unforced composite IP joint flexion. The finger is then straightened from the flexed position and extension range of the distal joint is carefully assessed for any sign of lag. While the splint is off. The splint should allow full PIP joint flexion range. i. care is taken to avoid restricting the circulation. then both IP joints will need to be included in the splint. as is often the case with an associated avulsion fracture. the splint may need to be adjusted until swelling has stabilized.g. A desirable DIP joint flexion range during the first week is 20 to 30 degrees. If the DIP joint flexion deformity appears to be recurring. Resisted activities are avoided until the 10th week. Hypermobile joints often require prolonged splinting. Full PIP joint mobility should be maintained throughout this period. If the patient demonstrates joint hypermobility. The DIP joint is maintained in full extension with a thermoplastic splint that can be worn volarly or dorsally. the splint can hold the DIP joint in slight hyperextension where this position can be gained with ease. Exercise sessions are performed every 2 h with 5 to 10 repetitions. The splint should be removed at least once each day to ‘air’ the finger and to check for adverse effects from the splint. while the DIP joint is held in neutral extension. gentle active DIP joint flexion exercises are commenced. (b) avulsion fracture of the base of the distal phalanx. Night and intermittent day splinting is maintained for a further 2 weeks.Extensor tendons 47 (a) (b) (c) Figure 4. If the mallet deformity has resulted in a secondary swan-neck deformity (i.e.e. Micropore or Hypafix) applied to the skin prior to splint application will help prevent maceration. . Whether the joint is splinted in neutral extension or slight hyperextension. The patient is instructed in skin and splint care. the skin is gently tapped and massaged to stimulate the circulation.

e. The 6-week splinting period is then commenced from that time. Oedema in the distal segment of the finger is managed with Coban wrap (25 mm). it can be left in place for about 10 days before it softens and needs replacing. Figure 4. Passive and active DIP joint exercises are performed hourly. Their extension force at the DIP joint becomes more concentrated. Management is then as for closed mallet injury. In most cases. 4. becomes a fixed deformity with PIP joint flexion contracture and DIP joint hyperextension contracture (Fig.g. An extension splint is then applied for a further 3 to 4 weeks. Because the finger is frequently swollen. Night splinting in a thermoplastic finger splint is maintained for a further 2 weeks. This will provide gentle even compression and will alleviate joint discomfort. . A variety of splints can be used to achieve this goal. if untreated. Suspected closed injuries of the central slip are treated by splinting which maintains the PIP joint in full extension for a period of 6 weeks. Buttonhole deformity following injury to the central slip of the extensor tendon.7. When this occurs. The lateral bands fall below the axis of the PIP joint and become flexors of this joint. Forced flexion of the joint will result in attenuation of the tendon and a recurrence of the deformity. This deformity results when the lateral bands fall below the axis of the PIP joint.8). The cast should not impede DIP joint flexion which should be carried out passively and actively on an hourly basis with 10 to 20 repetitions.8. The PIP joint is plaster-casted to maintain full extension. The cast may need to be changed every few days until swelling has fully settled. serial casting is used to overcome the flexion deformity prior to the 6-week splinting period which will begin when neutral extension range has been achieved. Central slip disruption Joint axis Lateral band Oblique retinacular ligament Zones III and IV Conservative management for closed injury Injury to the extensor tendon mechanism over the PIP joint can produce a buttonhole deformity which. the lateral bands become flexors of the joint while at the same time concentrating their extension force at the DIP joint. Gentle unresisted active PIP joint flexion/ extension exercises are commenced after 6 weeks of extension splinting. Capener or a circumferential plaster cast. Figure 4. resulting in DIP joint hyperextension. This further compounds loss of DIP flexion range which is often the most disabling aspect of this deformity.7). serial casting is undertaken until full extension range has been regained. The DIP joint is left free to move. Flexion of the PIP joint should be regained gradually over a number of weeks. Gentle dynamic flexion splinting of the DIP joint can be incorporated into the plaster to overcome tightness of the oblique retinacular ligament. 4. thermoplastic finger splint. Shortening of the oblique retinacular ligaments quickly ensues. In the presence of a flexion contracture. If the deformity presents late.48 The Hand: Fundamentals of Therapy Open injury Open wounds are best treated by repair and internal fixation of the distal joint with a K-wire which is removed 2 to 3 weeks later. a plaster cast is the splint of choice (Fig.

The wrist should be maintained in 30 degrees of flexion and the MCP joints maintained in neutral extension during the manoeuvre. the author does not use the second template used for active DIP joint flexion exercises. The position of extension is held for Figure 4.Extensor tendons 49 Open injury The traditional postoperative treatment following repair in Zones III and IV has involved immobilization of the PIP joint for a 6-week period.11. Implementation of the active short arc motion protocol as proposed by Evans (1994) has shown statistically superior results when compared with traditional management of these zones. 1990).10). this area is particularly prone to adhesion formation resulting in restricted tendon excursion. Minor modifications to the original protocol have been made. Coban wrap is used over the dressing to treat postoperative oedema. The prescribed exercises are performed with the wrist in 30 degrees of flexion and the MCP joint in neutral extension or slight flexion. Due to the significant tendon-bone interface and proximity to joint structures.e. With the volar template splint held in place. both IP joints are then actively extended to neutral extension. The author has now used this protocol for several years with good results.9.. The use of only one template (instead of two) during active exercise.10. 4. This extended position is held for several seconds before the manoeuvre is repeated. the interphalangeal joints are fitted with a thermoplastic finger splint that maintains both joints in full extension (i. 0 degrees). This splint is used every waking hour. 2. Figure 4. Maintenance of the fully extended position between exercise sessions is most important in avoiding elongation of the tendon (Fig. applied over a non-bulky dressing in a distal to proximal direction. the finger is wrapped in a single layer of Coban (25 mm) Figure 4. These include: 1. .9). the patient flexes both IP joints to the limit of the splint and then actively extends the digit to neutral extension at both IP joints. A volar template splint is then made which will accommodate 30 degrees of active PIP joint flexion and 25 degrees of active DIP joint flexion (Fig. One or two days following open repair of the extensor tendon in Zone III or IV. To help eliminate digital oedema. the digit is fitted with a thermoplastic finger splint that maintains both IP joints in full extension. A dorsal finger splint rather than a volar one. extensor lag and joint stiffness (Newport et al. The volar template splint allows 30 and 25 degrees of active flexion at the PIP and DIP joints. respectively. 4. Following active flexion to the limit of the volar splint. The initial splint may need to be replaced if postoperative swelling has been significant. Active short arc motion protocol Within a day or two of surgery.

4. particularly if the injury has involved other structures. Movement of this joint is important in maintaining excursion of the lateral bands and the oblique retinacular ligaments. The PIP joint must be kept in full extension during DIP joint exercises. Static extension splinting between hourly exercise sessions is maintained for 6 weeks. Closed injuries to the sagittal hood system over the MCP joints can occur with blunt trauma and result in an extensor lag or ulnar drift of the tendon. The exercise session is completed with active stabilized DIP joint flexion/extension exercises which maintain DIP joint mobility and excursion of the lateral bands and oblique retinacular ligament. As for Zones III and IV. The interphalangeal joints are maintained in full extension with a distal splint component that is removed for IP joint exercises. This exercise is repeated 10 to 15 times. this author has not used the static splinting method other than for patients considered unable to cope with the regimen. Prompt management of postoperative oedema is important in minimizing the risk of these adhesions. the propensity toward adhesion formation is great. adhesion of the repaired tendon to skin and bone does still occur.12). Postoperative management several seconds prior to again flexing to the limit of the splint (Fig. the distal joint is fully flexed and extended. and to 70 or 80 degrees by the end of the 4th week.12. tendon injuries in these zones can be managed by: 1.50 The Hand: Fundamentals of Therapy Zones V and VI These two zones lie between the MCP joints and the extensor retinaculum. Static splint and immobilization On the 2nd or 3rd postoperative day the plaster is replaced with a volar thermoplastic splint which maintains the wrist in 45 degrees of extension and the MCP joints in 0 to 20 degrees of flexion. This manoeuvre is repeated 20 times every hour. e. If no extensor lag has developed.g. Fully resisted activity is avoided until the 10th week. active DIP joint flexion is limited to 30 degrees for the first two weeks. 4. If the lateral bands have not been repaired. 2. active DIP joint flexion is limited to 30 degrees and is followed by active DIP joint extension. This is increased to 50 degrees by week 3. Because of the undisputed biochemical and biomechanical advantages associated with early controlled motion. Since starting on the dynamic protocol four years ago. Where they have undergone repair. the volar template splint is modified or replaced after 2 weeks to allow 40 degrees of PIP joint flexion during the described manoeuvre. Both methods of management will be described. These injuries are treated by splinting the involved MCP joint in neutral extension for a period of 4 to 6 weeks. Because the dorsum of the hand can accommodate significant swelling. Composite active finger flexion can begin at the end of the 5th week. The maintenance of IP joint extension is important in preventing palmar plate Figure 4. Tendon glide is more readily restored in these proximal zones because this area has greater soft tissue mobility. This can be performed by undoing the distal strap of the splint and stabilizing the PIP joint during active flexion of the distal joint (Fig. following a crush injury. Return of flexion range should be gradual so as not to jeopardize PIP joint extension range. bone and intrinsic musculature. The other component of the hourly exercise routine involves active flexion of the DIP joint with the PIP joint held in full extension. The controlled motion protocol in these zones was originally devised by Evans to overcome problems associated with complex injuries. Evans now also uses the dynamic approach with the simple tendon injury. Dynamic splinting and early controlled motion. .11). 1. If the lateral bands have been repaired. Nonetheless. Static splinting and immobilization.

13). This position reduces the passive tension of the opposing extrinsic digital flexors. 1993). Day 24 onwards At 31 weeks.Extensor tendons 51 Figure 4. The splint extends from two-thirds along the forearm to just proximal to the PIP joints so IP joint flexion can be performed (Fig.e. A removable distal component (not shown) is worn at night and between exercise sessions to prevent flexion deformity at the interphalangeal joints. active MCP joint extension exercises are performed with the wrist in 20 to 30 degrees of flexion. These are followed by IP joint passive extension. Postoperative splint following extensor tendon repair for Zones V and VI using the static immobilization protocol. ‘Place and hold’ extension exercises are performed with the wrist in 20 to 30 degrees of flexion while the fingers are supported in full extension. Because wrist flexion is synergistic with finger extension. The wrist is then extended to 45 degrees and the patient attempts 40 to 60 degrees of MCP joint flexion with the IP joints maintained in extension. This exercise is repeated 10 to 20 times every 1 to 2 hours. active IP joint flexion exercises are performed every 2 h with 10 repetitions. When the sutures are removed after about 10 days. The distal component of the splint is worn between exercise sessions to maintain full digital extension. soapy water (with care taken to maintain the correct position of wrist and finger extension) and gentle oil massage is begun. Days 3 to 24 Because IP joint motion produces only minimal extensor tendon excursion in Zones V and VI (Brand and Hollister. 4. the hand is bathed in warm. 3.14). This involves extending the MCP joints while maintaining maximum IP . All traces of oil are removed prior to application of the gel. and then actively extend the MCP joints to neutral extension.13.e. Figure 4. The supporting hand is then removed and the patient is asked to maintain active digital extension for several seconds. ‘Place and hold’ exercises are performed with the wrist supported in 20 to 30 degrees of flexion and the fingers supported in full extension (Fig. The supporting hand is then removed from the fingers and the patient is asked to maintain active digital extension with minimal exertion for several seconds before relaxing. contracture and subsequent flexion deformity. hold this position for several seconds. 4. Scar is managed with silicone gel which is worn beneath Tubigrip elastic stocking. The following exercises are performed: 1. is begun with the wrist held in 45 degrees of extension. The patient is then asked to actively flex the MCP joints to 30 degrees. extrinsic extension exercises are added to the programme. At week 6. all three finger joints flexing simultaneously). Full active IP joint flexion should be possible within the splint. i. composite flexion (i. gentle active motion of the MCP 2 joints is commenced. the ‘intrinsic-plus’ position. Protective splinting is maintained between exercise sessions until the end of the 6th week. At week 4.14. The third exercise involves active flexion and extension of the IP joints with the wrist in 20 to 30 degrees of extension and MCP joints held in neutral extension range. 2.

The digital slings maintain the MCP joints in neutral extension range. This manoeuvre is repeated 20 times at each hourly exercise session. rather than at the MCP joints. The patient can engage in light unresisted daily activity at this stage. The author of this protocol (Evans. Fully resisted activity is avoided until week 12 when the repair will have sufficient tensile strength. The finger slings are removed for this exercise and the MCP joints are maintained in full extension. Our patients are provided with a line diagram depicting the desired angle. The joints are returned to neutral extension by the rubber band traction.16. Gentle active IP joint flexion exercises are performed 4 to 6 times daily with 5 to 10 repetitions. This manoeuvre is repeated 20 times. the manoeuvre is practised on the opposite hand until the patient understands what is required. 4. our patients are asked to flex to 45 degrees after 2 weeks and to 60 degrees after 4 weeks. On an hourly basis. Narrow slings that sit beneath the proximal phalanx only. This can be effectively accomplished by holding a pen across the base of the proximal phalanges. the finger slings will need to be fairly wide and extend distal to the PIP joints.15). 1989) uses a volar blocking component during exercise to limit active flexion to 30 degrees. If wide finger slings do not prevent the IP joints from assuming a flexed posture.16). The tension of the rubber bands is checked daily to ensure that neutral extension range is being maintained (Fig.52 The Hand: Fundamentals of Therapy joint flexion and is performed with the wrist in neutral extension. will allow the IP joints to assume a flexed position. The patient actively flexes the MCP joints to a limit of 30 degrees every hour. small wooden ‘paddle-pop’ sticks can be inserted under the digit during MCP joint exercise sessions. Dynamic traction (using rubber bands that are connected to nylon thread). the patient will be practising extrinsic IP joint flexion exercises rather than intrinsic MCP joint flexion exercises. a gentle dynamic MCP joint flexion splint is applied. the patient actively flexes the MCP joints to a limit of 30 degrees and then allows the rubber band traction to return the MCP joints to neutral extension (Fig. Gentle active IP joint flexion exercises can be carried out with the wrist and MCP joints maintained in extension. there will be a strong tendency for flexion to occur at the already flexed IP joints. slings and held on with Microfoam tape will overcome this problem. When the patient then attempts active MCP joint flexion exercises. As a departure from the original protocol which has the MCP joints flexing to a limit of 30 degrees for the first 3 weeks. A dorsal forearm-based dynamic extension splint is fitted on the 3rd postoperative day. In other words. Figure 4. This splint holds the wrist in 40 to 45 degrees of extension. Prior to commencing the exercise. Dynamic splinting and early controlled motion A dorsal forearm-based dynamic extension splint is fitted to the patient within the first 3 days of surgery. To help maintain IP joint extension at rest and during active MCP joint flexion exercises.15. Flexion of the IP joints in this position creates only minimal excursion of the extensor tendon in Zones V and VI. thin thermoplastic finger splints used inside the finger Figure 4. maintain the MCP and IP joints at 0 degrees (or neutral) extension range. Splinting is maintained for a total of 6 weeks. Maintenance of interphalangeal joint flexibility is important throughout the splinting period. 2. 4. This . Alternatively. If MCP joint flexion range is still restricted by the 8th week.

Full passive mobility into extension reduces the resistance of the antagonistic flexors. interphalangeal joint flexion is maintained while the patient actively extends the MCP joints. Just as full passive IP joint flexion should be achieved prior to the commencement of active flexion following flexor tendon repair. a gentle compression bandage should be used postoperatively to help control and eliminate oedema promptly. 4.. 1991). maintain the extended position for several seconds. the therapist removes the supporting hand from the digits and asks the patient to maintain the extended position with minimal active effort for several seconds. i. The fingers are then relaxed and the MCP joints fall into a position of about 30 degrees of flexion. Extrinsic EDC extension exercises are performed by extending the MCP joints from the fisted position. Resistance is also created by dorsal hand oedema. The IP joints are then passively extended after each flexion exercise. Our patients are exercised into slight hyperextension if the opposite hand exhibits any degree of hypermobility. Where lag is present. When the finger joints can be placed in neutral extension with ease (i. If minimal active muscle-tendon tension (MAMTT) is to be incorporated into the therapy programme. At night. will accommodate almost complete IP joint flexion range while allowing good visualization of the MCP joints to ensure that they are maintained in full extension. 4. Minimal active muscle-tendon tension (Evans and Thompson. The therapist supports the patient’s wrist in 20 degrees of flexion and all digital joints in 0 degrees extension. It is based on the tenodesis effect resulting from the synergistic action between the wrist extensors and the finger flexors (Savage. 1993) This manoeuvre is the corollary of the ‘place and hold’ exercise used in the early active motion protocol following flexor tendon repair. the patient uses either a static volar splint that maintains the wrist and fingers in extension or a volar finger segment is added to the dynamic splint so that digital extension is maintained (Fig. 1985).e. A static volar splint can be used at night if the patient finds the dynamic splint awkward to sleep in. have formed (Gelberman et al. no resistance is perceived during passive extension).e. 1988).18.e. so too. full passive extension of all three digital joints is a prerequisite to the commencement of ‘place and hold’ active extension exercises. MAMTT is practised only in therapy. is utilized following extensor tendon injury. extrinsic extension exercises are instituted. The converse situation.17. This manoeuvre is repeated 20 times before the hand is returned to the splint..Extensor tendons 53 Figure 4. i. Figure 4. It has been experimentally demonstrated that the expected reduction in tensile strength following repair can possibly be prevented if the repair site undergoes very early stress (Amiel et al. . which would limit tendon glide. it should be done so within 24 h of surgery before collagen bonds. For this reason. The majority of patients are able to demonstrate full composite flexion following removal of the splint at 6 weeks and extensor lag is rarely seen. The patient is then asked to actively extend the MCP joints to neutral (0 degrees) extension and again. Patients should avoid fully resisted activity until 12 weeks following repair (Fig.17).18). that wrist flexion is synergistic with finger extension.

If finger or thumb extensors are involved. Zone V is in the region of the extensor retinaculum and injury to the EPL in this zone is considered complex because the tendon is synovial at this level. the injury is treated conservatively with a dressing and support splinting of the IP joint. Silicone gel is applied to scar as soon as the wound has healed. Gentle active thumb joint flexion is Injury to the thumb extensors Zone I Zone I is the area over the IP joint. a static splint is fitted which holds the wrist in 40 degrees of extension and the thumb in radial abduction with the MCP and IP thumb joints in neutral extension (Fig. Figure 4. Evans (1995) advocates that management of the tendon in this zone should involve early controlled passive motion and/or MAMTT exercises because dense adhesions at this level often limit excursion of the repaired tendon. IV and V Zone III is the area over the MCP joint and may involve one or both of the thumb extensors (i. Support splinting between exercises is maintained for 4 to 6 weeks.54 The Hand: Fundamentals of Therapy Zone VII At this level the extensor tendons pass beneath the extensor retinaculum. holding the IP joint in extension at night. it usually sustains only partial laceration. Between the 3rd and 4th week. and III. ECRB or ECU). Tendon laceration in this zone is repaired and followed by 6 weeks of extension splinting. A distal component. Scarring is usually significant in this zone following repair. The static postoperative splint for EPL repair holds the wrist in 40 degrees of extension and the thumb in radial abduction. . the wrist is splinted into 40 to 45 degrees of extension for a period of 5 weeks while the fingers are left free to move. the splint is removed every 2 h for gentle active thumb exercises.19). If wrist extensors alone have been repaired (i. the aftercare is the same as for Zones V and VI in the digits.e. If the laceration involves less than 50 per cent of the tendon. Care should be taken to avoid placing the MCP joint in hyperextension. Closed injuries are treated with continuous IP joint extension (or slight hyperextension where possible) splinting for 8 weeks. Mallet thumb is quite rare. 1. Active wrist flexion exercises are commenced after this time. See ‘Zones I and II’ (fingers) for exercise protocol. EPL or EPB). Surgical repair is carried out for more significant lacerations. Zone II This zone involves the proximal phalanx and injury to the tendon is usually secondary to laceration or a crush injury rather than avulsion. Static splinting and immobilization If the immobilization method is used postoperatively. is added to the splint to avoid the IP joint developing a flexion deformity. The tendons in this area are sufficiently thick to allow the use of standard coretype sutures.19. See ‘Zones I and II’ (fingers) for exercise protocol. Repaired tendons in this area have a tendency to adhere to one another as well as to the adjacent extensor retinaculum. If only the EPB tendon is involved. 4. The thumb MCP and IP joints are held in neutral extension. Zones III. The fingers are left free to move. ECRL.e. the IP joint is left free to move. Here the tendons are prone to proximal retraction. care should be taken to avoid hyperextension of the MCP joint during splint fitting. Zone IV is the area over the metacarpal. In the case of hypermobile patients. A further 2 weeks of intermittent splinting is maintained after IP joint flexion exercises have been commenced. The thumb IP joint is then splinted in full extension for 6 weeks. IV and V for thumb zones (see below). Gentle active motion is commenced after 10 days. Because the tendon has increased width in this zone and curves over the phalanx.

D. 4. and Siegel. D. A. Due to periarticular thickening. B. D. After the 3rd week. If the patient finds the dynamic splint awkward during sleep. The patient actively flexes the IP joint to 60 degrees every hour with 20 repetitions. Mackin and A. The patient performs active IP joint flexion to a range of 60 degrees every hour during the day. and Hollister. movements of the thumb can be practised with the wrist in all positions. A. In The American Academy of Orthopaedic Surgeons: Symposium on tendon surgery in the hand. 72. Early active short arc motion for the repaired central slip.Extensor tendons 55 practised with the wrist held in maximum extension. and McGrouther. Harwood. Boyes. E. Evans. a static splint is used at night. 565–606. Mosby. Hunter. (1989). Gelberman. Elliot. The ‘place and hold’ MAMTT exercises described in the previous section can be employed after the first day of surgery with the permission of the treating surgeon. The application of stress to the healing tendon. IP joint at 0 degrees extension. Early dynamic splinting for extensor tendon injuries. References Amiel. 262–80. and Burkhalter.. . Mosby Year Book. P. 6. This results in 5 mm of tendon excursion at Lister’s tubercle. the thumb can be actively exercised with the wrist in all positions. Controlled passive motion following flexor tendon repair in zones II and III. In Rehabilitation of the Hand: Surgery and Therapy (J. R. 991–7. The rubber band traction returns the IP joint to neutral extension. B. Care is taken to avoid a posture of hyperextension at the MCP joint. and Thompson.. J. 4. 2. These exercises are repeated 5 to 10 times during the first week after which repetitions are increased. Callahan. (1994). Duran. Clinical Mechanics of the Hand.. After the 6th week. Wrist in 40 degrees of extension. (1995). Hand Ther. IV and V holds the thumb IP joint is held in a position of neutral extension by rubber band traction. Evans. Hand Surg.. Z. When the splint is removed after 6 weeks. B. R. The excursions of the long extensor tendons of the hand. If this is the case. The support is then withdrawn from the thumb and the patient gently holds the extended thumb position with minimal effort for several seconds. J. The dynamic splint used following EPL repair in Zones III. 11B. R. (1986). Active thumb extension is not performed with the wrist held in extension. J. H. B. composite thumb flexion and opposition with the wrist in extension can be begun. Hand Surg. E. (1970). By the 5th week. eds) pp. The thumb should not be involved in fully resisted activity until after the 12th week. 19A. R. Figure 4. The dynamic traction sling is applied to the distal phalanx (Fig. B. CMC joint in neutral extension. Protective splinting between exercise sessions is maintained for 6 weeks. 3. E. Matrix II. R. Evans. W. 11A. R.20). G. 77–80. After each active flexion exercise. 2. D. W. J. A. Dynamic splinting with controlled mobilization: used for Zones III.. Fibronectin in healing flexor tendons subjected to immobilization or early controlled passive motion. MCP joint in 0 degrees extension. Bunnell’s Surgery of the Hand. (1993). and Ribik. 184–9. A study of the dynamic anatomy of extensor tendons and implications for treatment. Lippincott. 11. F. and Houser. C. (1975). the patient relaxes the thumb and allows the rubber band traction to return the joint to neutral extension. Hand Surg. ‘Place and hold’ MAMTT thumb extension exercises are commenced by allowing the wrist to go into 15 to 20 degrees of flexion while holding the thumb in full extension. E. M. J. Brand. Browne. J. 53.. (1986). An update on extensor tendon management.. R. J. regaining flexion at the MCP joint can sometimes be difficult. D. (1993). 14A. Hand Surg. Mosby. J. see p. D.20. 774–9. gentle active MCP joint flexion is commenced out of the splint with the wrist maintained in extension. (1991).. Evans. IV and V following EPL repair The dynamic splint maintains the wrist and thumb in the following position: 1. J. gentle dynamic flexion splinting can be instituted between the 6th and 7th week.

J. Rupture of the central slip of the extensor hood of the finger: a test for early diagnosis. J. 11A. L. J. 17A. Anatomy of the dorsal aponeurosis of the human finger and its functional significance. Kim. M. Hand Surg. (1983). (1986). R. K. A.. C. 157–69. (1949). J. T. T. Hand Surg. J. L. J. Hand Ther. P. 30. P. A. Aoki. Bone Joint Surg. 68B. and Desai. 16A. rheumatoid arthritis and Dupuytren’s disease. Tokita. (1993). Hand Clin. J.. Extensor tendons-acute injuries. (1989). C.. (1986). Evans. Surg. J. J.. D. and Rutledge. K. E. 794–8. . J... (1992).. Choban. R. M. 106–10. M. and Williams. Eaton. (1988). 262–8. Chan. von Schroeder. (1985). W. (1990).. 548–52. 15A. P. (1990). Long-term results of extensor tendon repair. 18A. J. Hand Surg. Jr. F. Hung. L. Stern. Gelberman. (1992).. (1991). Harris. In Green’s Operative Hand Surgery (D. Chow.. F. Hand Surg. L.. Hand Surg. Hand Surg. and Steyers. C. W. J. von Schroeder. H. 14B. 187–201. 13A. J. Trans. B. Savage. Dynamic extension assist splinting of acute central slip lacerations. 8(35). J. M. 47. 20A. Manske. 25. and Torii. Spiegelman. Gelberman.. Hand Surg. B. H. Green.. Hand Ther. T... R. Orthop. Traumatic and spontaneous dislocation of extensor tendon of the long finger. Landsmeer. et al. A review and new proposals. (1986). (1967). A. L.. J. R.. L. R. Hand Surg. M. J. Electrophysiologic basis of dynamic extensor splinting. 1041–9. R. 1950–87. J. J. H. H. Saldana. 13B. Doyle. L. 821–3. Evans. 776–84. Postoperative management of repair of extensor tendons of the hand-dynamic splinting versus static splinting. 27–34. Botte. H. Hand Surg. A. 10B. M. Clin. (1999). J. P. and Mullins. M. 229–33. Report of the committee on tendon injuries.. An analysis of factors that support early active short arc motion of the repaired central slip. Hand Surg. Ther. 11A. P. and Botte. Mosby. 5. E. Jr. and Akeson. Hand Surg. R. L. J. Joint Dis.. eds) pp. Evans. 31–44. Hand Surg. J.. R. (1986). P. and Kastrup. B.. C. Maddy. R. (1999). The finger extensor mechanism. J. Biomechanical characteristics of suture techniques in extensor Zone IV. Conservative treatment of mallet thumb. Chang. G. 206–12.. R. 11A. J. and Shukla. and Meyerdierks. Jr. D. Patel. The functional significance of the oblique retinacular ligament of Landsmeer. Hand Surg. 54A. S.. Hand Surg. J. 15A. (1996). S. J.. 415. The excursion and deformation of repaired flexor tendons treated with protected early motion. (1987). The extensor mechanism of the fingers. Hand Surg. Ishizuki. 272. (1990)... M. (1995). (1989). and Verdan. 8A. Dovelle.56 The Hand: Fundamentals of Therapy Elson. (1995). R. Skin necrosis complicating mallet finger splinting and vascularity of the distal interphalangeal joint overlying skin. 10A. 45–7. 10.. H.. Tensile strength of cross-stitch epitenon suture. and Akeson. Results of acute Zone III extensor tendon injuries treated with dynamic extension splinting. F. 251–7. R. 650–6. Hotchkiss and W. J. Surg. Rayan.. J. Hand Surg. 2. (1988). 1–20. Early controlled active mobilization with dynamic splintage for treatment of extensor tendon injuries.. (1986). J. 11.. Ho. S. Anat. 104. Anatomy of the extensor tendons of the fingers: variations and multiplicity.. P. R. Hand Surg. G. Pederson. G. 229.. (1972). Blair. Lipson. Vande Berg. 18–20. L. Dovelle.. Pollack. J. Further reading Bendz. N. D. 258–9. J. Nakamura.. Conservative treatment for a ruptured extensor tendon on the dorsum of the proximal phalanges of the thumb (mallet thumb). W.. Miura. and Thompson. 15A... E. 713. A. (1987). The functional significance of the long extensors and juncturae tendinum in finger extension. and Schacherer. P.. Newport. S. 68(12).. Bull. and Saldana. B. Hand Surg. Rec. G.. C. M. J. J. J.. M. Masson. Newport. Hand IV: extensor tendons. M. G. (1985). J. W. Therapeutic management of extensor tendon injuries. Phys. A. J. A comparison of results of extensor tendon repair followed by early controlled mobilization versus static immobilization. Littler. 39–47. 641–7. P. Bone Joint Surg. 12A. M. S. J. Hand Surg. P. S. J. 32. M. Westerbeck. Hosp. Complications and prognosis of treatment of mallet finger. 961–6... and Botte.. M. Selected Readings in Plast. J. North Am. The influence of wrist position on the minimum force required for active movement of the interphalangeal joints.. Newport. (1997). J. Kleinert. and Callahan. (1969). 1145–50. S. Clinical application of controlled stress to the healing extensor tendon: a review of 122 cases. 20A. 967–72. S. J. Thomas.. Chow.. and Ishii. The early stages of flexor tendon healing: A morphologic study of the first fourteen days. 21B. J. S. The functional anatomy of the extensor mechanism of the finger. T.. R. Thomas.

The peripheral nerve carries three types of nerve fibres. This thin. 1988). etc. This discontinuity in the myelin sheath allows rapid impulse conduction as the action potential leaps from one node to the next (Fig. i. lamellated sheath protects the contents of the endoneurial tubes.1). The epineurium cushions the fascicles from external pressure and allows movement of . the median nerve has the greatest proportion of autonomic fibres. The unmyelinated gaps between the segments of the myelin sheath are called nodes of Ranvier and are about 1–2 mm apart. Meissner’s corpuscles or as free nerve endings. the perineurium. 1982). Axoplasmic transport mechanisms move these substances to the periphery (antegrade transport) where breakdown products are then returned in a proximal direction (retrograde transport). fasciculi or funiculi which are the smallest units of the nerve that can be surgically manipulated. The axonal transport occurs at speeds that vary from about 1–400 mm per day (Weiss and Gorio. Epineurium The epineurium is the outermost layer and is located between the fascicles and superficially in the nerve. polypeptides. Unmyelinated fibres are mainly small sensory fibres that conduct pain impulses from the skin. Sensory fibres originate from cell bodies in the dorsal root ganglia and terminate at receptors such as Pacinian corpuscles. enzymes. motor. e. Motor nerve fibres originate from cell bodies in the ventral horn of the spinal cord and terminate at the neuromuscular junction. The nerve fibres (or axons) extend from the nerve cell body to the receptor organs in the motor and sensory endplates (Fig. acts as a mechanical barrier to external forces and provides a diffusion barrier that keeps certain substances out of the intrafascicular environment (Lundborg. connective tissue and blood vessels. Most peripheral nerve axons are covered by a myelin sheath which is produced by flattened cells known as Schwann cells.5 Peripheral nerve injuries Anatomy and pathophysiology Peripheral nerves are complex composite structures comprised of nerve fibres.g. proteins.. 5. Perineurium The nerve fibres with their related endoneurium form aggregations called bundles. are synthesized within the cell body and are necessary for the normal function and survival of the axon. free amino acids. This sheath has great mechanical strength and strongly resists longitudinal traction. The endoneurium is the supporting collagenous tissue of the individual fibres.2). Endoneurium There are successive layers of connective tissue surrounding the nerve fibres. sensory and autonomic. It takes part in the formation of the ‘endoneurial tube’ which contains the myelinated axon and associated Schwann cells.e. Various substances. In the upper limb. The proportion of fibres in each nerve depends on the function of that nerve. Fascicles are enclosed by the next connective tissue layer. 5.

1949). these vessels divide into ascending and Endoneural tissue layer Schwann cell Myelin sheath Axon Node of Ranvier Figure 5. The amount of epineurial connective tissue can vary enormously (25–75%) among nerves and at different levels within the same nerve (Sunderland and Bradley. The epineurium is often more abundant in areas requiring greater protection such as where the nerve is in close proximity to bone or a joint (Sunderland. .2.) one fascicle upon another. Most peripheral nerves are covered by a myelin sheath.1. 1978). 1970. Nerve vasculature The peripheral nerve contains vascular networks in the epineurium. Anatomy of a nerve cell showing the cell body and the nerve fibre (axon) with its component parts. Upon reaching the nerve. with permission. the perineurium and the endoneurium. The blood supply to the peripheral nerve as a whole is provided by large vessels that approach the nerve segmentally along its course.58 The Hand: Fundamentals of Therapy Figure 5. (From Grabb. The unmyelinated gaps between the segments of the myelin sheath are called nodes of Ranvier.

Sir Herbert Seddon has described three levels of injury: neurapraxia.e. The classification described by Sir Sidney Sunderland has five categories of injury. The cell body and proximal axon stump enlarge to satisfy the metabolic requirements for regeneration. proximally and distally to the lesion. neurotmesis. Axonotmesis Axonotmesis is a more severe form of nerve injury with disruption to the continuity of axons within the nerve.3. When there has been axonal disruption. electrical current or the late effects of radiation. The budding axons grow toward the distal segment and advance along the Schwann cell columns. 1975). however. Types of nerve injury Nerves can be injured through trauma (laceration. as far as the next node of Ranvier. The 3rd and 4th levels of injury in the Sunderland classification refer to . the 1st. descending branches that run longitudinally and frequently anastomose with the vessels in the perineurium and epineurium. compression (acute or chronic). crush or burn). i. Neurotmesis Seddon’s last category of nerve injury. 2nd and 5th of which correspond to the above three. together with the Schwann cells. axonotmesis and neurotmesis. respectively. refers to a complete transection of the nerve with loss of integrity of the perineurium and epineurium and corresponds to the 5th category described by Sunderland. clear the endoneurial tube of debris in preparation for axon regeneration. ischaemia. Neurapraxia Neurapraxia is the mildest form of nerve injury and axonal continuity is maintained. (b) Nerve regeneration. This injury involves a localized block to conduction. There should. be good functional recovery because the supportive connective tissue remains intact so that axonal regeneration is specific to the end organ. there is degeneration of the axon and myelin sheath distal to the wound and proximally. stretching (traction). Wallerian degeneration of the distal axon will occur. Because there has been axonal disruption. nerve conduction is preserved. Functional recovery can take some months depending on the level of the disruption and how far regeneration needs to occur. Degeneration is initiated by the ingrowth of macrophages which. (a) Nerve degeneration. The more common nerve injuries are those involving lacerations which can be either partial or complete.Peripheral nerve injuries 59 Figure 5. however. The microvascular system has a large reserve capacity because axonal transport and impulse propagation depend on a local oxygen supply (Lundborg. A full recovery is expected and is usually complete within weeks or several months.

muscle nutrition or the age of the patient. The maximum rate of axonal outgrowth in humans is about 1 mm per day (Fig. Nail changes include ridging and furrowing. Degeneration and regeneration 1. at the most distal remaining node of Ranvier. thereby giving a better result. These grow towards the distal segment and then advance along the endoneurial tubes (or Schwann cell columns). however. intraneural haemorrhaging and oedema will often result in scar tissue formation.g.. Degeneration is initiated by the ingrowth of macrophages which trigger the proliferation of Schwann cells. Where possible. with the muscle fibres gradually being replaced by fibrotic tissue (Bowden and Gutmann. 5. These initial sprouts are usually resorbed. pain. 2. This occurs proximal to the nerve lesion.g. spatial discrimination (e. The regulation of axon growth and orientation is complex and reliant on a variety of biochemical and biomechanical mechanisms. The more accurate the matching of sensory to sensory and motor to motor nerve fibres. muscle stretching. Where the nerve lesion is in continuity. Nerve repair The nerve is repaired as accurately as possible to facilitate the regeneration of axons down the distal connective tissue tubes. slowed growth and hardening. localization.60 The Hand: Fundamentals of Therapy varying degrees of intraneural disruption and loss of fascicular integrity that can result from moderate to severe traction and crushing injuries where the epineurium remains intact. Effect on associated tissues Muscle changes Muscle fibres usually undergo moderate to severe atrophy by three months and moderate to severe fibrosis after about one year. Skin that is smooth and dry is said to have reduced ‘tactile adhesion’ (Moberg. 1944). 1989) (Fig. The interruption to the flow of axoplasm results in an accumulation of axoplasmic substances at the proximal stump. The degree of atrophy and fibrosis varies significantly among individuals and can be affected by infection. Vasomotor changes Following complete nerve disruption. patients with a compression neuropathy may show abnormality when tested with a threshold test such as the Semmes-Weinstein monofilaments. medial cutaneous nerve of the forearm) is undertaken to avoid tension at the . the hand becomes increasingly cool to the touch and readily affected by the surrounding temperature (Sunderland.3(a)). the better is the potential reinnervation of the end organs (Fig. After a three-year period. two-point discrimination) and functional gnosis. 1962). temperature. 1995). Colder weather is troublesome for most patients with nerve injury. light touch. muscle fibres exhibit progressive fragmentation and disintegration.e.3(b)). Sensory loss A completely severed nerve will result in loss of sensibility involving the various sensory categories. Axon regeneration Severed axons begin to send out a great number of sprouts within six hours of injury. Even if the perineurium has remained intact. 1975). 1978). Wallerian degeneration Degeneration of the distal axon begins at the level of injury. sural nerve. In the presence of wound contamination or associated injuries. the denervated hand will be warm to the touch for the first 2 to 3 weeks due to vasodilation resulting from paralysis of the vasoconstrictors (Seddon. The macrophages and Schwann cells clear the Schwann cell tube of myelin and axoplasm in readiness for subsequent axon regeneration (Stoll et al. Disruption of sympathetic nerve function affects tissue nutrition. where degeneration occurs only as far as the next node of Ranvier. e. 1999).g. This facility is important in preventing the slippage of objects when gripping or when performing fine manipulative tasks (Clark. permanent sprouts are formed a day later. 5. When injured. making skin more vulnerable to injury.4). denervated skin usually takes longer to heal. Atrophy of the epidermis results in decreasing prominence of the papillary ridges and there may be reduction or absence of hand sweating. but give a normal response to functional tests such as moving or static two-point discrimination (Callahan. pressure. secondary procedures are performed when conditions are more favourable. After this time. primary repair of the nerve is undertaken. making nerve regeneration less likely. i. grafting with a suitable donor nerve (e. Where there is a gap in the nerve. the pattern of loss can be variable. 5.

e. 5. however. Healing of nerve repair The repaired nerve sheath. whether epineurium or perineurium.) repair site which will encourage proliferation of scar tissue. Higher magnification is required to identify and better align the fascicular groups which should be repaired without tension. joint mobilization can commence earlier. Green. It is more difficult to match like axons with a nerve graft. 4. eds) p. (a) Laceration. Meissner corpuscles). e. The repair is splinted without tension during this time.g. Nerve suture techniques.4. To avoid tension at the repair site. Factors affecting nerve regeneration Factors that can affect regeneration of nerve following injury or repair include: 1. with permission. N. The finger portion of the splint should allow full IP joint extension. 1387. Nerve repair and grafting.Peripheral nerve injuries 61 Figure 5. Digital nerve repair The digital nerves are the most frequently severed peripheral nerves (Clark. Individual fascicular repair is only rarely performed. The patient should aim for full intrinsic IP joint extension to the limit of the splint to avoid the development of a PIP joint flexion deformity. (c) Group fascicular suture. Pederson. digital nerve repairs are protected for three weeks with a dorsal hand-based splint that maintains the MCP joints in 50 to 70 degrees of flexion. (Reproduced from Brushart. M. Accuracy of fascicular alignment. R. Hotchkiss and W. the less likelihood there is of a favourable outcome). Epineurial repair is the most common technique and is used for the completely transected nerve. fractures. The age of the patient (with increasing age there is a reduction in receptor populations. Perineurial (or fascicular) repair is the second most commonly used technique of nerve repair. (d) Individual fascicular suture. Degree of scar tissue. takes 3 weeks to gain sufficient tensile strength to withstand stress. Gentle IP joint exercises can be performed within the splint. (b) Epineurial suture. i. 2. Associated injuries. In Green’s Operative Hand Surgery (D. 3. tendon injuries. . Churchill Livingstone. T. soft tissue loss. The level of injury (the more proximal the lesion. This technique allows for greater accuracy in matching fascicles of similar size. 1999. because there is complete absence of tension. This is the simplest type of repair. C. 1999). Technique The proximal and distal nerve stumps are isolated and every attempt is made to preserve the vascular attachments. P. requiring minimal magnification and a minimum number of sutures.

massage is light otherwise it cannot be tolerated due to hypersensitivity. Scar softening and desensitization at the repair site are commenced. skin. Desensitization exercises are performed at the repair site. full passive finger flexion range should be established prior to the commencement of active motion. 3. the hand is rested in a dorsal splint which maintains the wrist in slight flexion to avoid stress on the repair. Initially. the patient will need to compensate visually until protective sensation has returned. That paraesthesia (tingling or pins and needles) and hyperaesthesia (painful hypersensitivity) are normal manifestations of nerve regeneration and will diminish with time and use of the hand. Later stage postoperative management (4 to 6 weeks) Gentle active wrist movements are commenced after 4 weeks. Active wrist extension is initially carried out with the fingers held flexed as there is often considerable tethering of structures. 68). Where there has been flexor tendon involvement. Following repair of the median or ulnar nerve at the wrist. To minimize stress on the tendon repair. Following the 3-week splinting period. Sensory retraining is begun when moving-touch can be perceived in the fingertip (see p. the flexor tendon protocol is used unless the surgeon advises that gentle early active movement is allowed. That muscle wasting increases in the early stages following nerve injury. the hand is rested in a dorsal splint which maintains the wrist in slight flexion. The splint is worn for 3 to 4 weeks by which time there is sufficient connective tissue strength to withstand wrist movement (Fig. Scar management and desensitization Sutures are removed 10 to 14 days after surgery. Patient education Patient education is an important aspect of management following a peripheral nerve lesion. resulting in soft tissue tightness. How to avoid injury and take care of anaesthetic skin. 2000). How to avoid deformity due to muscle imbalance by corrective splinting and maintaining mobility of joint and soft tissue structures. Figure 5.e. As tolerance to touch improves. the patient should avoid digital hyperextension for the next 1 to 2 weeks. 5. gentle active finger and thumb movements can be commenced within the splint 1 to 2 days after surgery when the inflammatory response has subsided. . That the average rate of nerve regeneration is approximately 1 mm per day. The gel is also helpful in acting as a ‘shock absorber’ over the repaired nerve. Gentle oil massage should be carried out four to six times a day as part of a home programme. A layer of Opsite Flexifix over the affected area often helps ‘dampen’ these unpleasant sensations (Boscheinen-Morrin and Shannon. Nerve injuries at the wrist are frequently associated with tendon injuries. Nerve regeneration is often accompanied by unpleasant paraesthesia or hyperaesthesia. 5. 2. Patients should be informed of the following: 1. Scar massage is begun following suture removal. 4.5. dry. Extreme hypersensitivity is managed with transcutaneous electrical nerve stimulation (TENS).62 The Hand: Fundamentals of Therapy In the case of the thumb. a small hand-based thumb post can be fitted which holds the MCP joint in 35 to 40 degrees of flexion while permitting motion at the IP joint. The splint extends just beyond the tips of the fingers with the thumb remaining free. Scar tissue that is dense and/or raised is managed with silicone scar gel which is applied to clean. i. oil-free skin.5). In the absence of tendon injuries. nerve and tendons. The patient is instructed in skin care and how to avoid injury to anaesthetic skin. pressure is gradually increased. Early postoperative management following nerve repair at the wrist After a median or ulnar nerve repair at wrist level.

5. The patient can attempt to actively extend the fingers and wrist simultaneously if flexor tightness has been overcome. particularly areas of altered or absent sensibility. serial casting is continued until full simultaneous wrist/digital extension has been achieved. Where gripping is a problem. Finger movements are Figure 5. .Peripheral nerve injuries 63 Figure 5. Week 6 onwards Gentle resistance is added to flexion and extension exercises. the hand can be soaked in warm water for 10 to 15 minutes to improve comfort and mobility.7. The splint is used during the night and intermittently throughout the day. are checked regularly for signs of pressure areas. To promote effective tendon glide. The wrist and fingers are casted in a position of correction that provides only a negligible stretch. active finger and thumb exercises should be performed individually with stabilization of more proximal joints (Fig. Prior to exercise.6). Wearing time may need to be increased slowly from initial periods of 1 to 2 hours.7).6. active movement of the fingers and thumb occurs as a ‘mass’ action. This process can sometimes take several months. The skin. Overcoming soft tissue tightness A mild flexion deformity of the wrist can be managed with a cock-up wrist splint which holds the wrist in neutral or slight extension. Where soft tissue tightness remains. the use of a thermal glove for protection in winter is recommended. The patient is encouraged to use the hand for light daily activity. The initial cast should hold the wrist and fingers in the position achieved by the patient when asked to actively extend to maximum range (Fig. Protection in cold weather As the nerve-injured hand is vulnerable to the effects of the cold. interphalangeal joints should be exercised with stabilization of the more proximal joints. serial extension casting is commenced between the 4th and 5th weeks. more effectively performed when the wrist is supported in slight extension with a brace or thermoplastic splint. If the flexion deformity involves the wrist and fingers. This position should not cause pain and the fingertips are checked for signs of skin blanching that indicate excessive pressure. Hand oedema is managed with a lycra pressure glove which will also exert a gentle extension force to the digits. To promote tendon glide. Serial plaster casts are used to overcome soft tissue tightness on the volar aspect of the wrist and/or fingers. 5. The patient is advised to perform short exercise sessions on an hourly basis with at least 10 to 15 repetitions of movement. This may require functional splinting to oppose the thumb in a median nerve lesion or the use of an anti-claw splint in an ulnar nerve lesion. Tendon adherence Due to adherence of soft tissue structures at the repair site. utensils can be ‘built-up’ with Handitube.

The combined loss of sensibility and thumb opposition significantly affects hand function. Skin should be nourished regularly to maintain suppleness. the following muscles are affected: abductor pollicis brevis. Loss of thumb opposition. 2. the hand is referred to as a ‘simian’ or monkey hand because of the flat appearance of the thenar musculature and the inability to rotate the thumb to oppose the digits. pronator quadratus (anterior interosseous branch). Figure 5. Note the anterior interosseous syndrome with loss of function of FPL and FDP to the index finger. Loss of flexion to the thumb IP joint and finger flexion (other than FDP action to the ring and little fingers). Power grip is also affected because of the loss of the stabilizing action of the thumb. 2. Specific nerve lesions Median nerve In a median nerve lesion. This median nerve lesion was sustained during a crush injury to the forearm.9. Weak radial deviation of the wrist. Note also the blister on the tip of the index finger from contact with a kettle. flexor digitorum profundus (FDP) to index and middle fingers (anterior interosseous branch). flexor pollicis brevis and opponens pollicis (these three muscles comprise the thenar eminence) and the 1st and 2nd lumbricals.8. 3. . at wrist level).e. Apart from the potential danger of heat and sharp implements. shiny. This results in: 1. The thumb tends to lie beside the index finger because of the unopposed action of extensor pollicis longus and adductor pollicis (Fig. Frequently used utensils and tools can be padded to avoid these problems.8). 5. Low lesion In a low lesion (i. palmaris longus (main branch) and flexor digitorum superficialis to all digits (main branch) (Fig. patients should be alert to pressure areas that can arise from friction during activity or pressure areas resulting from prolonged contact of the denervated area with splints or simply resting against a hard surface.9). fragile and prone to injury. In a median nerve lesion the thenar eminence has a flat appearance and the thumb lies beside the index finger because of the unopposed action of extensor pollicis longus and abductor pollicis. flexor carpi radialis (main branch). pronator teres (main branch of median nerve).64 The Hand: Fundamentals of Therapy Care of denervated skin Denervated skin becomes smooth. Figure 5. Loss of thumb palmar abduction results in an inability to grasp larger objects such as a glass. High lesion A high lesion (elbow or neck) involves the following muscles in addition to the abovementioned: flexor pollicis longus (anterior interosseous branch of median nerve). Loss of forearm pronation. This results in: 1. 5. Hyperextension of the MCP joints of the index and middle fingers from overaction of the extensor digitorum communis (EDC).

Serial C-splints are used to overcome a tight thumb web that can develop following a median nerve lesion. Figure 5. Lively splint A rotation strap made from neoprene or stretch tape (e. Microfoam) is used to bring the thumb into palmar abduction and opposition to facilitate pinch grip (Fig.11). An ulnar nerve lesion results in a claw deformity of the ring and little fingers regardless of the lesion level. Contracted thumb web space. Figure 5.g. .13.Peripheral nerve injuries 65 Trick movement In a low-level median nerve lesion. pinch grip is achieved by the action of flexor pollicis longus and adductor pollicis against the radial side of the index finger. this can be overcome with serial C-splints that gently stretch the web space (Fig.11. A rotation strap will elevate the thumb from its adducted posture and reposition it in opposition to the index and middle fingers. 5. Figure 5. 2. prolonged contact with hard surfaces or friction ‘burns’ during prolonged activity.12).12. Associated problems 1. 5.10). 5. Figure 5. Injury to skin (Fig. Anaesthetic skin is very vulnerable to injury from contact with hot surfaces.10.

only two other muscles are affected: flexor carpi ulnaris and flexor digitorum profundus to the ring and little fingers. This can be troublesome during writing. 2. Patients are encouraged to practise desensitization exercises frequently throughout the day. Abduction deformity of the little finger The abductor digiti minimi is the first muscle to recover following an ulnar nerve lesion at the wrist. This results in: 1. As recovery proceeds. In the absence of adductor pollicis. 5. finger adduction is mimicked by relaxation of the digital extensors and contraction of the extrinsic finger flexors. adductor pollicis. 5. i. The wrist falls into approximately 45 degrees of flexion because the wrist flexors are unopposed by the wrist extensors. Pinch grip is also affected through loss of the first dorsal interosseous muscle and adductor pollicis. The thumb falls . This results in: 1. Loss of thumb adduction. 5. In the absence of the 3rd and 4th lumbricals. 4. In the absence of the dorsal interossei function. Hyperaesthesia along the ulnar border of the hand Nerve regeneration can be accompanied by hypersensitivity. High lesion (above the elbow) Together with the muscles involved in a low lesion. the IP joints of the little finger will markedly flex to compensate for the lack of 5th metacarpal elevation owing to loss of opponens digiti minimi function.14).66 The Hand: Fundamentals of Therapy Ulnar nerve An ulnar nerve lesion results in a claw hand regardless of the level of the nerve lesion. particularly in the case of the index and little fingers which have a second extensor. all dorsal interossei.13). i. attempts to flex the MCP joints of the ring and little fingers will result in acute flexion of the IP joints of these digits. this is known as Pollock’s sign. Weakened ulnar deviation of the wrist because of unopposed action of extensor carpi ulnaris. 2. 4. 2. opponens digiti minimi (these three muscles comprise the hypothenar eminence). The principle of these splints is to support the MCP joints in flexion thus allowing the long extensors to act on the IP joints in the absence of the ulnar-innervated intrinsics. flexor digiti minimi. Claw deformity This deformity can be controlled with a variety of anti-claw splints. Covering the affected area with a layer of Opsite Flexifix can often help to reduce sensitivity. Clawing of the ring and little fingers – this is due to loss of the interossei and the unopposed action of extensor digitorum communis and extensor digiti minimi. all palmar interossei and the medial two lumbricals. This loss results in instability in pinching the thumb against the index finger (Froment’s sign). adduction of the thumb to the index finger is achieved through the combined action of flexor pollicis longus and extensor pollicis longus. 3. extensor indicis proprius and extensor digiti minimi. This posture can sometimes interfere with function. the little finger can be buddy-strapped to the adjacent ring finger during activity. On attempting to oppose the little finger to the thumb. Power grip is significantly diminished in an ulnar nerve lesion. Loss of flexion at the DIP joints of the little and ring fingers.e. The MCP joints of the ring and little fingers assume a position of hyperextension and IP joint flexion (Fig. Inability to elevate the 5th metacarpal to enable effective opposition between the thumb and little finger. This is known as Bouvier’s manoeuvre (Fig. respectively. In the absence of volar interossei function. the little finger becomes progressively abducted. Associated problems 1. Trick movements 1. finger abduction is mimicked by the digital extensors. Low lesion (wrist level) The following muscles are affected: abductor digiti minimi. Radial nerve A radial nerve lesion results in a wrist drop deformity. this posture is known as Duchenne’s sign. 3. Loss of finger abduction and adduction. To overcome this. the lumbricals to the ring and little fingers. 3.e. 2.

15. 5. into flexion and palmar abduction because the thumb intrinsics are unopposed by abductor pollicis longus. extensor digitorum communis. 3. Thumb IP extension is achieved during palmar abduction owing to the accessory insertion of abductor pollicis brevis into the extensor apparatus. Elbow extension (high lesion). The MCP joints of the fingers fall into slight flexion because the intrinsic hand muscles. (a) The static ‘spaghetti’ splint controls the hyperextension deformity of the MCP joints and facilitates full interphalangeal joint extension by maintaining the MCP joints in slight flexion. extensor pollicis brevis and abductor pollicis longus.15). the following muscles are affected: triceps. Trick movements 1. brachioradialis function). Splinting A lively radial palsy splint can restore the reciprocal tenodesis action of finger extension-wrist Figure 5. There may appear to be contraction of the wrist extensors following strong finger and wrist flexion.14. 2. Note also that the MCP joints have not fallen into flexion because of skin contracture following extensive grafting. This results in loss of: 1. are unopposed by extensor digitorum communis. extensor carpi ulnaris. . extensor carpi radialis longus. flexion of the MCP joints will be observed due to compensatory efforts by the intrinsic muscles whose action is to flex the MCP joints and simultaneously extend the IP joints.Peripheral nerve injuries 67 (a) (b) Figure 5. (b) The splint does not hamper finger flexion and therefore allows the hand to function. i. the interossei and lumbricals. Where this is the case. Note that the thumb has not fallen into palmar abduction because the median nerve was also affected.e. extensor carpi radialis brevis. extensor pollicis longus. extensor pollicis longus and extensor pollicis brevis (Fig. This wrist drop deformity resulted from injury to the radial nerve following a crush injury. When the patient attempts to extend the fingers. Digital MCP joint extension. Wrist extension. brachioradialis. Flexion of the elbow with the forearm in midposition (i. Thumb extension. 4. 3. Patients with a radial nerve palsy have poor grip function owing to a lack of stabilizing action of the wrist extensors. The most common site of radial nerve injury is at the radial groove of the humerus.e. 5. this is purely due to relaxation of the flexors. 2.

Hand function can also be significantly enhanced with a simple cock-up wrist brace which places the wrist in 30 to 40 degrees of extension. Sensory retraining after median nerve repair Patients with a sensibility deficit have the ability to adapt and compensate for this loss if they are well motivated and prepared to engage the hand in dayto-day activities (Onne. These higher cortical functions. (b) When the patient actively flexes the fingers. This splint utilizes static tension by way of nylon monofilament. weight. The best known of these re-education programmes are those described by Wynn Parry and Slater (1976) and Dellon et al. (1974). The aim of retraining is to improve stereognostic ability. the recognition of an object by assessing its shape. and thereby expedite this process. size and texture.17). 1962).68 The Hand: Fundamentals of Therapy (a) (b) Figure 5. Patients achieve a functional degree of digital extension using the intrinsic musculature to extend the IP joints (Fig. To release objects. the wrist is brought into a functional range of extension. flexion and finger flexion-wrist extension. A formal sensory re-education programme can utilize learning principles such as attention. 5. This splint employs a static suspension line (nylon thread) (Fig. The slightly extended wrist accommodates optimal function of the finger flexors and enables grasp. When the hand is relaxed. Figure 5. 5. .e.17. it is important to maintain wrist support to prevent stretching of the dorsal hand structures. sufficient digital extension is usually gained through the intrinsic musculature which extends the interphalangeal joints.16. Regardless of the type of splint used. will help patients to interpret the altered sensory impulses that reach the brain from the peripheral nerves. This results in improved functional dexterity even though two-point discrimination may be sub-optimal. Surprisingly good function can be achieved with a simple wrist cock-up splint. It is the experience of this author that most patients reject the lively splint in favour of the static wrist brace when provided with both splints. (a) In a radial nerve palsy a lively splint can restore the reciprocal tenodesis action of finger extension-wrist flexion and finger flexion-wrist extension. i. the splint maintains the wrist and fingers in neutral extension. feedback. memory and reinforcement.16). whilst not able to speed up axonal regeneration or create the formation of receptors.

Moving-touch can be assessed with the examiner’s fingertip or with Semmes-Weinstein monofilaments which should record 4. towelling and silk. and Shannon. The patient is encouraged to slowly move the blocks in the hand.. Formal sensibility testing for nerve regeneration can be carried out every 6 to 8 weeks (See Chapter 1 – ‘Assessment’).g. relies on the hand being engaged in daily use so that the training effect is not lost. More textures and objects are added to the programme as the patient demonstrates progress (Fig. the patient is reproducing Figure 5. Retraining incorporates both moving. . velvet. 2000). In this way. (2000). If localization is incorrect. thereby gaining impressions of smooth surfaces and corners. sheepskin. The maintenance of this dexterity. carpet. The patient is then asked to identify the area with eyes opened. 5. J. Sessions should be kept short and should take place in a quiet environment to eliminate distraction. sensory retraining is begun. in slow motion what the normal hand does automatically and with great speed. J. When these have been mastered. shapes and everyday objects With vision occluded. Progress can be recorded on a grid pattern. the patient is asked to describe a variety of textures. localization of the stimulus may be inaccurate. Larger objects are used before smaller objects are introduced. Occup. in turn. e. Reinforcement by repetition is integral to training. Retraining sessions can be curtailed when the patient has attained the desired level of functional dexterity. 1995). The types of objects used in testing and training should reflect the everyday experience of the patient. ‘prickly’ or ‘spongy’. The final stage of sensory retraining involves trying to identify everyday objects. gleaning information regarding its size. ‘smooth’. shape.18. the patient moves the texture over the affected area again while watching the manoeuvre so that the tactile-visual image can be reinforced. leather. temperature and texture.18). (submitted for publication September. the patient is encouraged to explore the object slowly. Localization While the patient may be able to perceive the monofilament or fingertip. With the eyes closed. Discrimination training using textures. Ther. Aust. Treatment parameters Sensory retraining sessions should ideally be performed four times each day. density. precedes discriminative touch (Callahan. The process is then repeated using different shaped blocks.31 or lower to qualify for retraining. J.Peripheral nerve injuries 69 Timing of programme commencement When the patient is able to discern moving-touch in the fingertips. pimple rubber. Again. The final stage of retraining involves the use of everyday objects. Movingtouch perception returns ahead of constant-touch perception. the patient progresses to smaller sizes. References Boscheinen-Morrin. the stimulus is again applied with the patient observing the manoeuvre and integrating both the visual and sensory impressions. These should initially be quite different to allow for easy discrimination and can include textures such as: sandpaper. The patient is encouraged to describe his sensory impressions. Opsite Flexifix: an effective adjunct in the management of pain and hypersensitivity in the hand. Larger sizes are used initially. as this description will often help the patient deduce the texture. ‘rough’. Moving-touch precedes light touch which.and constant-touch. Different areas of the palm and fingertips are then tested and retrained. however. the stimulus is applied to the skin. Where distinction is poor or inaccurate.

Li. (1995). C.. Churchill Livingstone. eds) pp. D. and Gutmann. D. 163. J. Mackin and A. T. F. 428–49. E. Sensory re-education after median nerve lesions. Peripheral nerve injuries: pathophysiology and strategies for treatment. Smith. C. Adv. Churchill Livingstone. Plast. (1981). C. 2(Suppl. J. Butler. Bone Joint Surg.. E. M.. Primary suture is best. Kendall. L. Lundborg. Birch. Perth.. (1983). J. Wallerian degeneration in the peripheral nervous system: participation of both Schwann cells and macrophages in myelin degradation. Churchill Livingstone. B. B. 624–8. G. A. M. 72. Stoll. Acta Chir. In Rehabilitation of the Hand: Surgery and Therapy (J.) 300. M. C. E. E. S. Surg. 21–31. N. Hunter. S. 790–6. A. Hand Surg. (1995). et al. R. (1989). T. Curtis. questions and facts. 1381–403. E. Springer-Verlag. Chassard. 20. (Suppl. and Raji. M. J. Structure and function of the intraneural microvessels as related to trauma. (1949). Dellon. eds) pp. Nerve Injury and Repair. eds) pp. M. eds) pp. J. 771–84. M. D. G. 8–19. M. J. Callahan. B. 179. The anatomy and physiology of nerve injury.. 45–68. Mosby. R. D. and Edgerton. Churchill Livingstone. Nerves and Nerve Injuries. Callahan. Reeducation of sensation in the hand after nerve injury and repair. Peripheral nerve regeneration: strategies to augment specificity. K. (1982). and Salter. Weiss. J. 8. Sensory rehabilitation in the hand. Millesi. A. and Dellon. 18. Sunderland. Clin. C. Axoplasmic Transport in Physiology and Pathology. (1993). A. 769–78.. M. E. P. D. Pederson. M. Sensibility testing: current concepts. L. In Rehabilitation of the Hand: Surgery and Therapy (J. (1995). 18B. In Hand Rehabilitation (Clinics in Physical Therapy Series) (C. In Rehabilitation of the Hand: Surgery and Therapy (J. 129–52. J. R. D. i. M. E. Australia. Criticism and study of methods for examining sensibility in the hand. Sensibility measurement and management. 1–69. M. 264. Lundborg. (MSc – coursework). E. Mosby. Orthop. The cross-sectional area of peripheral nerve trunks devoted to nerve fibers. J. Thesis. D. Operat. 45–7. Mackin and A. (1978). and Comtet. Gerostathopoulos. edema formation and nerve function. 6. An analysis of the results of late reconstruction of 132 median nerves. Moran. Moran. W. T. (1999). Clark. R. 12. Mosby. (1994). S. J. K.. Hunter. Peripheral nerve repair. Splinting the hand with a peripheral nerve injury. Hand. Brain. Neurology. Muscles – Testing and Function. Hand Surg. P. Terminology. 13. Callahan. J. and Gorio. 679–92. H. Lundborg. J. 73B. Pham. B. J. Acta Orthop. W. Reconstr.. and Callahan. 609–626. Saunders. and Bradley. 18B. (1993). and Jabaley. 18B. In Rehabilitation of the Hand: Surgery and Therapy (J. 250–7. L. Hunter.) pp. Hotchkiss and W. Re-education of sensation in the hand following nerve suture. Moberg. Digital nerve repair: The relationship between sensibility and dexterity. G. Mobilisation of the Nervous System. H. A. Lancet. A. Sunderland. Churchill Livingstone. eds) pp. G. C. J. Onne. Curtis. Jerosch-Herold. Recovery of sensibility and sudomotor activity in the hand after nerve suture. A. Microsurg. In Green’s Operative Hand Surgery (D. Bowden. Denervation and reinnervation of human voluntary muscle. Green.). 53. P. 273–313. and Vastamaeki. 135. (1975). ed. (1944). Hand Surg.. R. (1962). and Trapp. Callahan. A. (1990). Sensibility assessment: prerequisites and techniques for nerve lesions in continuity and nerve lacerations. (1975). Hunter. Nerve repair and grafting. Griffin. 67. (1993). Reinnervation of denervated Meissner corpuscles: a sequential histologic study in the monkey following fascicular repair. Dellon. eds) pp. W. J. Hand Surg. A.. Misitzis. Sunderland. Brain. (1986). Mackin and A.. E. Bone Joint Surg. 671–83. Dellon. J. Curtin University of Technology. Sensory re-education after peripheral nerve injury.. (1962). 98. Neurocytol. Two-point discrimination tests versus functional sensory recovery in both median and ulnar nerve complete transections. 57A. Omer and M. 75. K. Scand. Nerve response to injury and repair. 2. (1985). Callahan. T. L. S. Conolly. Williams & Wilkins. D. 109–28. L. J. C. (1991).. .. Orthop. D. L... M. M. Clinical assessment of primary digital nerve repair.. (1974). Reconstr.. Hand Ther. Suppl. D. Spinner. J. Wynn Parry. (1976). Measuring outcome in median nerve injuries. (1980). In Management of Peripheral Nerve Injuries (G. (1993). Churchill Livingstone. and Morrin. Further reading Bell-Krotoski. Y. Muscle Nerve. (1999). Mosby. 154–7.70 The Hand: Fundamentals of Therapy Brushart. N. Colditz. Scand. J. M. Kallio. G. 938. J. (1995). Brushart. Repair of median and ulnar nerves. Efstathopoulos. Mackin and A. (1988). 297–305. (eds) (1982). Surgical Disorders of the Peripheral Nerves. (1991). A. 1. M. R. 97–105. (1995). Seddon.

A progressive neuropathy. 4. All surgical stages must be planned prior to the first procedure. Contracture of joints or skin that would limit movement. (1981) and abstracts from their charts are given in the table below. Lack of a suitable muscle or muscles for transfer. hand function can be improved by the transfer of an expendable muscle-tendon unit with the aim of restoring balance to the hand. Prerequisites for tendon transfer 1. nerve damage following radiation therapy. e. Because this is constantly changing. a contracted thumb web. The excursion of a muscle is determined by the length of its fibres. The strength of a muscle is proportional to its cross-sectional area and is expressed as a tension fraction. it is important to know the strength of the muscle and its excursion. e. the resting fibre length is recorded. All skin and soft tissue in the vicinity of the transfer must be pliable and mobile. 3. Any preexisting soft tissue adherence will prevent effective tendon glide of the transferred tendon. Surgical considerations Choice of transfer tendon The retraining of muscle function following transfer is easier when there is synergism between the muscle’s original function and its new action . e. Selected early transfers can optimize sensibility reeducation when performed in the dominant hand (Citron and Taylor. 1987). When choosing transfers.g. will require correction prior to surgery.6 Tendon transfers Where muscle function has been lost through injury or disease.g.g. 1997). All joints that will be affected either directly or indirectly by the transfer must be fully passively mobile as transferred tendons cannot move or correct stiffened or contracted joints. 2. The muscle-tendon unit to be transferred must be sufficiently strong to perform its new function in its altered position. any soft tissue tightness. 4. Complicating medical conditions. Also. Preoperative preparation A full muscle assessment of the arm is undertaken to determine precisely which muscles are affected and to ascertain which muscles can be used for transfer. Contraindications 1. The patient must be a suitable candidate for reconstructive surgery. muscle spasm or circulatory inadequacy. 2. 3. These measurements have been determined by Brand et al. A muscle-strengthening programme is devised for the patient to carry out independently so that motivation and commitment to therapy can be evaluated (Warren.

7 2.1.1 2. natural ‘tracks’ should be used.3 5.5 1. Expendability of the donor The removal of a tendon for transfer should not leave an unacceptable loss of function.4 1.0 0. If the transfer cannot perform its new function with a straight line of pull. Tension of transfers The proper tension in a transfer is critical to the outcome of the procedure. FCR or FCU) should be used as palmaris longus is an inadequate substitute for their loss. only one of the two main wrist flexors (i.6 5.4 5. Where possible. If passage through a sheet of fascia is necessary.0 3. e.g. The transfer pathway The most efficient transfer is one that passes in a direct line from its origin to the insertion of the tendon that it is substituting. 1999). 1999). The use of superficialis tendons may be an exception to this because there is more independent cortical control compared to other muscles in the hand (Green.9 2.5 4.1 Tension fraction (%) 1. Acute angulation of the transfer at the pulley should be avoided. The effectiveness of a tendon transfer is reduced when it is expected to produce two dissimilar functions even when they are not directly opposed (Green.1 6. Tunnels need to be wide enough to permit free passage of the tendon. as should incisions along the new line of the transferred tendon. fascia or muscle. Alphabetic list of the main muscles of the forearm with resting fibre length and tension fraction Muscle Resting fibre length (cm) 4.1 3.5 Abductor digiti minimi Abductor pollicis brevis Abductor pollicis longus Brachioradialis Extensor carpi radialis brevis Extensor carpi radialis longus Extensor carpi ulnaris Extensor digitorum communis Extensor digiti minimi Extensor indicis proprius Extensor pollicis brevis Extensor pollicis longus Flexor carpi radialis Flexor carpi ulnaris Flexor digitorum profundus Flexor digitorum superficialis Flexor pollicis brevis Flexor pollicis longus Opponens pollicis Palmaris longus Pronator teres (average) (average) (average) (average) (Davis and Barton. If a new one is needed.4 4.7 1.7 5.9 2.5 7.3 4. Incision sites The suturing of skin directly over tendon sutures should be avoided.8 1.2 6. it should pass through no more than one pulley.1 1. 1999).5 4.2 4.3 4.1 6. there should be no force used when tunneling through tissues such as scar. For some transfer . Single or dual insertion techniques Tendon transfers are most efficient when they perform only one active function.1 9.4 1.5 5.9 1.7 4.3 2.0 1.1 3.0 5.2 3.72 The Hand: Fundamentals of Therapy Table 6.9 5.6 5.6 16.0 5. The creation of a tunnel by force is likely to result in adhesions.e. there should be sufficient excision to minimize obstructing adhesions.

The success of opponensplasty will be determined by the quality of sensibility. a flap is raised using the anterior half of the flexor carpi ulnaris tendon. tension must be carefully estimated and a certain level of experience is necessary before the surgeon develops the ‘feel’ for proper tension.1. the Healing times The repair is either tendon to tendon or tendon to bone and requires about 4 weeks of healing before it is safe to subject it to the stress of active movement. prominent knots or potentially irritating non-absorbable sutures. Requirements prior to opponensplasty for low level lesion (wrist) 1. Opponensplasty for low median nerve palsy using FDS of the ring finger as motor. e. Mobile thumb joints. tenodesis of the PIP joint is performed to prevent a secondary hyperextension deformity. tidy suturing is required. e. long threads. 1949). Figure 6. Most tendon junctions stretch in the first three months and it is better to err on the side of slightly too much tension than not enough. Opponensplasty for median nerve palsy Abductor pollicis brevis is the prime muscle of thumb opposition. About 3–4 cm proximal to the wrist.g. should not be left exposed as they may irritate and/or cause adhesions. the standard thumb opponens replacement. For others. 4. Loose tendon ends. 3. 2. silk. thumb abduction and opposition are frequently retained because of the variability of thenar muscle innervation. To prevent migration of the pulley. Where patients exhibit joint hypermobility.g. 1984).Tendon transfers 73 procedures. It is then fashioned into a loop with a 1 cm central diameter and serves as a pulley (Bunnell. The basic requirements for restoring thumb opposition were established by Bunnell (1938) who identified the pisiform as the best location for a fixed pulley because this keeps the transfer in line with the abductor pollicis brevis muscle. Tendon junctions Where grafts are used to extend tendons or where there are mid-tendon junctions. Full mobility of the unaffected digits. The flexor pollicis brevis muscle frequently has dual median and ulnar nerve innervation (Rowntree. Following a complete lesion of the median nerve. Normal or maximal thumb web span. Supple skin so that the tendon transfer is not limited by subdermal scarring. The flap is elevated as far as 1 cm proximal to the tendon’s insertion into the pisiform. Opponensplasty using superficialis of the ring finger Technique The superficialis tendon of the ring finger is harvested through an incision in the distal palm to avoid injury to the flexor sheath at the level of the PIP joint. . Some opposition is also produced by opponens pollicis and flexor pollicis brevis (Cooney and Linscheid. Healing also occurs along the course of the transferred tendon and can result in adhesions to surrounding tissues. 1938). In the case of a high median nerve lesion in adults. sensory recovery is usually poor and the benefit of this procedure is doubtful. tensions have been determined.

the game pieces should not be too small and can be covered with a textured fabric to enhance grip. 6. such as playing board games. As sensory recovery may still be suboptimal. The flexor retinaculum and ulnar border of the palmar aponeurosis can provide an alternative pulley to the one described (Thompson–Royle transfer. the patient can be asked to touch the thumb to the little finger or to pick up a light object. This action should produce some thumb abduction and opposition. If the PIP joint has . With the wrist held in mild flexion and the other digits trapped in extension. the thumb IP joint can be immobilized in extension with a small thermoplastic splint to isolate the action of the transfer. active abduction and opposition are practised with the hand in all positions.2. the splint is worn between exercise sessions and during sleep. The position of immobilization following opponensplasty has the wrist in neutral extension and the thumb in full opposition with the IP joint held in extension.2). One slip is attached as far distally as possible to the abductor pollicis brevis tendon and the other. To help facilitate this spontaneity. 6. it may be necessary to slightly ‘straighten’ the wrist so that a little tension is placed on the transfer to help facilitate its action. Weeks 4 to 6 The hand is taken out of the splint and active use of the transferred tendon is commenced. Weeks 0 to 4 During the first 3 to 4 postoperative weeks. Figure 6. distally based slip of FCU can be attached to the tendon of extensor carpi ulnaris (Sakellarides. the patient is asked to flex the donor finger. 1970) (Fig. Exercise and activity sessions are kept short at this stage to avoid fatigue of the transferred muscle. 1999). should be encouraged. Throughout this fortnight. Gentle active finger movements can be performed. the transfer is completely immobilized to protect the tendon junctions. 1942). the ring finger. 1995). Non-resistive activity. it should be splinted in about 45 degrees of flexion during the immobilization period. During this period. If the postoperative plaster is comfortable and maintains the correct position. The fingers are left free to move. however. Postoperative management The wrist is immobilized in neutral extension with the thumb held in full opposition and the IP joint of the thumb held in extension to protect the attachment to the extensor mechanism (Fig. If this is not occurring. The superficialis tendon is divided into two slips. into the extensor apparatus. i. From the 5th week onward. it need not be replaced. It is important to emphasize wrist movements as these alternately relax and tighten the opponensplasty (Davis and Barton. The patient should perform 6 daily sessions with each session lasting between 5 and 10 minutes (Stanley. more distally.74 The Hand: Fundamentals of Therapy been tenodesed to prevent hyperextension deformity. the splint should be checked regularly to ensure that it is comfortable and that the correct position is being maintained. If the patient is overusing flexor pollicis longus during active exercise.e. This action is repeated until the patient is able to demonstrate spontaneous movement of the thumb.1).

R. 1993) and restores palmar abduction rather than opposition (Fig. . N. There can be several anomalous neural patterns of the ulnar nerve in the forearm and hand. N.3. Figure 6. C. 1980). Median nerve palsy. there is dual innervation to the third lumbrical and this would result in clawing of the little finger only in a low level palsy.3). Week 6 onwards Graded resistance is applied to the transferred tendon by way of exercise and activity. 1509. and Barton. This may result in all of the lumbricals being innervated by the median nerve in which case there would be no clawing of the digits. The wrist is maintained in neutral extension with the thumb in opposition and the MCP joint in extension. Churchill Livingstone. The palmaris longus transfer is usually attached to the insertion of abductor pollicis brevis (Terrono et al. extensor carpi ulnaris. J.) Ulnar nerve palsy The classic ulnar claw deformity is not always apparent following injury to this nerve. 2.. Green. Extensor indicis proprius opponensplasty This transfer has an advantage over the superficialis transfer in that it does not compromise gross grip strength through the loss of a digital flexor (Burkhalter et al. The splint is maintained for 4 weeks and formal therapy is rarely required following this procedure. (Reproduced from Davis. eds) p. In 50 per cent of upper limbs. The ulnar border of the wrist is used as a natural pulley and the transfer is inserted into the tendon of abductor pollicis brevis. Because extensor indicis proprius has a relatively short excursion. 3. Alternative procedures 1. 6. Camitz palmaris longus opponensplasty This procedure is used for patients with a functional disability related to severe carpal tunnel syndrome and can be performed at the same time as carpal tunnel release. with permission. 1999. Pederson. R. In Green’s Operative Hand Surgery (D. The Camitz opponensplasty utilizes the palmaris longus tendon which is lengthened with a strip of palmar aponeurosis and attached to the abductor pollicis brevis insertion. Hotchkiss and W.. the wrist should be immobilized in 30 degrees of flexion so as to relax the transfer during the immobilization period (Davis and Barton. 1973). The transfer should be able to withstand normal loading 12 to 14 weeks after surgery.Tendon transfers 75 Scar softening is an important part of the home programme during this time. the median nerve partially or completely innervates the first dorsal interosseous muscle with rare innervation by the radial nerve also occurring (Kaplan and Spinner. Less commonly used transfers These include: abductor digiti minimi (Huber). Silicone gel is used at night and in between exercise sessions. T. In 10 per cent of hands. 1999). Massage and pressure therapy are continued until scar resolution has been achieved. P. Oil massage along the scar line should be carried out 4 to 6 times daily. extensor carpi radialis longus and extensor digiti minimi. C.

6. Wrist in 45 degrees of extension. result in increased grip strength (Hastings and McCollam. Superficialis transfers are designed to integrate MCP joint and IP joint motion. The thumb remains free (Fig. The graft is split into two slips which attach to the radial sides of the proximal phalanges of the ring and little fingers. 6.5). i. 2. The PIP joints must be fully mobile in passive extension and the MCP joints fully mobile in passive flexion.76 The Hand: Fundamentals of Therapy Preoperative requirements for low level ulnar nerve lesion 1.4). The graft is split into two slips that are passed through the intermetacarpal spaces between the long/ring and ring/little fingers respectively (Fig. IP joints in full extension. 2. Intrinsic transfer using extensor carpi radialis longus The extensor carpi radialis longus tendon is lengthened with a free tendon graft using palmaris longus (or plantaris). on the radial aspect of the proximal phalanges of the ring and little fingers. 1994). The smaller extensors. Suitable muscle-tendon units include: flexor digitorum superficialis. Each slip is then passed volar to the deep transverse metacarpal ligament and inserted into a drill hole. extensor indicis proprius and extensor digiti minimi (quinti) can provide intrinsic function with the transfer of a muscle to two fingers each (original Fowler technique) (Fig. The use of a wrist extensor to flex the MCP joints will improve gross power grip. Figure 6. The Fowler transfer for ulnar nerve palsy uses the EIP and EDQ (or EDM) tendons. . Many surgeons transfer to all four fingers. 4. They do not. Available donors Tendon transfers in an ulnar nerve palsy aim to restore flexion of the MCP joints and thumb adduction. 6. Figure 6. Almost any tendon that crosses the wrist can be used. flexor carpi radialis.5. however. Soft tissues should be free of contracting scar and have adequate circulation.4. Intrinsic transfer using extensor carpi radialis longus.6).e. extensor carpi radialis brevis. The tendon is lengthened with a free graft using palmaris longus (or plantaris). extensor carpi radialis longus. Postoperative management The hand is splinted in the following position: 1. 3. each divided into two slips. brachioradialis and palmaris longus. MCP joints in 70 degrees of flexion.

the therapist places light pressure over the PIP joints. The patient should perform this exercise on a 1 to 2 hourly basis with 5 to 10 repetitions during the 1st week of active exercise. thereby holding the MCP joints in 20 Weeks 0 to 4 The hand and forearm are maintained in the described position for the first postoperative month. IP joints in full extension and the thumb remaining free. emphasis is placed on active flexion and extension of the fingers while maintaining MCP joint flexion. Capsulodesis of the MCP joints A short flap of the MCP joint volar plate is drawn proximally and sutured into the neck of the metacarpal. cutlery. i. Weeks 6 to 12 Light gripping activities are commenced. there will be a slight relaxation of the positions of wrist extension and MCP joint flexion. The position of immobilization following intrinsic transfer using ECRL is as follows: wrist in 45 degrees of extension.g. Each slip is attached in one of three ways (Fig. the handles of everyday utensils. e. The patient is then asked to actively extend the wrist which should result in some MCP joint flexion. By the 2nd week. By the 5th week.Tendon transfers 77 maintained during this manoeuvre. 6. Into a drill hole in the proximal phalanx.7): 1. intrinsic flexion. it may be necessary to change the cast after several days so that the position of immobilization is not lost. palm up and with the hand on the side. To the lateral band of the dorsal apparatus (this insertion is associated with a high incidence of swan-neck deformity). 2. Static procedures 1. the patient learns to localize the action of MCP joint flexion without having to extend the wrist and practises the movement with the hand in all positions. 6. Into the A1 or A2 pulley of the flexor sheath. Superficialis transfer The superficialis tendon of the middle (long) or ring finger is divided into 2 slips (for the ring/little fingers only) or 4 slips for all digits. MCP joints in 70 degrees of flexion. To prevent further extension of the MCP joints. If postoperative swelling has been significant. Graded resistance is applied to MCP joint flexion with the IP joints extended. 3. Alternative dynamic procedure Figure 6. Weeks 4 to 6 When the hand is removed from the splint and placed on the table. Gentle active wrist flexion is also begun. MCP flexion of 60 to 70 degrees and full extension of the IP joints (Fig. can be temporarily enlarged to encourage function. Extension of the IP joints should be . i.6.e. The activity programme is upgraded to restore maximum power grip. Workers involved in manual work can return to employment after the 14th week. The position of immobilization is: wrist in slight flexion (15 to 20 degrees). If active finger flexion is incomplete.e.8). The hand is returned to the splint after each exercise session until the end of the 6th week.

. The thumb in ulnar nerve palsy Figure 6.5 cm to the middle of the proximal phalanx. ECU) is passed from the lateral band of the dorsal extensor apparatus to the deep transverse metacarpal ligament in the palm where it is sutured with the MCP joint in 45 degrees of flexion.78 The Hand: Fundamentals of Therapy degrees of flexion (Zancolli. 1973). 1966). 2. Patients with ulnar nerve palsy lose 75 to 80 per cent of pinch grip power (Mannerfelt. Figure 6. into the A1 or A2 pulley or into a drill hole in the proximal phalanx. 3. Flexor pulley advancement (Bunnell. The tendon is hatched back to the level of the flexor retinaculum and divided into four slips (coloured black) which are rerouted volar to the deep transverse metacarpal ligament. Each grafted finger functions independently (Parkes. The superficialis transfer for ulnar nerve palsy using the FDS tendon of the middle (long) or ring finger. thereby increasing movement across the MCP joint. The adduction force in key pinch comes primarily from adductor pollicis and the radial head of the first dorsal interosseous muscle (Omer. Postoperatively. Restoration of pinch grip power following tendon transfer ranges between 25 and 50 per cent of normal. The position of immobilization following a superficialis transfer holds the wrist in slight flexion because of the flexor route of the transfer. 1957).g.8. 1999). 1942) The A2 pulley is split on each side for 1.7. This results in ‘bowstringing’ of the flexors.5 to 2. this position must be maintained for at least 6 weeks. ECRL. Static tenodesis A free tendon graft (e.. The slips are attached either to the lateral band of the dorsal apparatus.

In the absence of associated injury to the median and ulnar nerves. Preoperative requirements 1. When the wrist cannot be stabilized in extension. 3. brachioradialis. 2. There must be a full range of forearm supination/pronation. but provide only modest improvement in power. extensor indicis proprius. Arthrodesis Fusion of either the MCP or IP joint of the thumb is an alternative to tendon transfer and can provide greater stability for pinch grip function. The wrist extensors and brachioradialis require lengthening with free grafts. The MCP joints must be passively mobile in extension. Flexor digitorum superficialis (ring finger) to extensor indicis proprius and abductor pollicis longus. The thumb web space must be normal. Flexor carpi radialis to abductor pollicis longus and extensor pollicis brevis. the following functions will need to be restored: 1. Index abduction Tendon transfers to improve abduction of the index finger give some stability during pinch. Thumb extension and abduction. The early transfer of pronator teres to extensor carpi radialis brevis significantly improves hand function (Burkhalter. The following transfers are used to insert into the tendon of the first dorsal interosseous: abductor pollicis longus (extended with a free graft). palmaris longus (lengthened with palmar fascia). the index finger is held in abduction and extension with the wrist in slight flexion for a period of 3 weeks after which active movement is commenced. 3. There must be full range of elbow flexion and extension. The superficialis transfer Radial nerve palsy The classic ‘wrist drop’ resulting from a radial nerve palsy has significant consequences for hand function. 5. The FCU transfer Pronator teres to extensor carpi radialis brevis. 1974). Finger extension (at the MCP joints). Palmaris longus to rerouted extensor pollicis longus. The FCR transfer Pronator teres to extensor carpi radialis brevis. Flexor digitorum superficialis (middle finger) to extensor digitorum communis. Tendon transfer for radial nerve palsy The most commonly used transfers to restore extension to the wrist. Palmaris longus to rerouted extensor pollicis longus. 2. available. brachioradialis. Early tendon transfer is an option for providing an ‘internal splint’ to enhance function while awaiting nerve regeneration. Postoperatively. Flexor carpi ulnaris to extensor digitorum communis. The wrist must be passively mobile in extension. extensor indicis proprius. 3. 1995).Tendon transfers 79 Corrective procedures 1. Where the radial nerve is irreparable. 4. Thumb adduction The restoration of thumb adduction can be achieved with a variety of transfers using the following donors: extensor carpi radialis brevis. thereby seriously impairing grip function (Reynolds. 2. the power of the long flexors is minimized. Wrist extension. extensor carpi ulnaris and flexor digitorum superficialis. . Flexor carpi radialis to extensor digitorum communis. extensor pollicis brevis and flexor digitorum superficialis. extensor carpi radialis longus. there are many transfer options Pronator teres to extensor carpi radialis longus and brevis. MCP joints and thumb joints include: 1. 3. 2.

3. The thumb is held in maximum extension and abduction. The splint is removed every 2 h and the . MCP joints and thumb in extension. Thumb in maximum extension and abduction. creating a combined abduction-extension force to the thumb (Fig. wrist in 45 degrees of extension and MCP joints in 10 to 15 degrees of flexion. 4. however does not cause undue tension on the suture lines.9).9. Weeks 4 to 6 The long arm splint is replaced with a short arm version that is worn for another 2 weeks and maintains the wrist. Postoperative management Splint position (Fig. Forearm in about 30 degrees of pronation. 6. MCP joints in 10 to 15 degrees of flexion.80 The Hand: Fundamentals of Therapy EPL EDC PL APL FCU PT ECRL and ECRB Figure 6. Pronator teres is stripped with its periosteal insertion from the radius. 6. Sutures are removed 10 to 14 days after surgery. Wrist in 45 degrees of extension. The position of immobilization after FCU transfer for radial nerve palsy is as follows: elbow in 90 degrees of flexion. Extensor pollicis longus is rerouted out of the extensor retinaculum. forearm in about 30 degrees of pronation. Flexor carpi ulnaris is freed extensively to create a direct line of pull from its origin to its new insertion into the tendons of extensor digitorum communis (using an end-to-side junction) just proximal to the extensor retinaculum. Flexor carpi ulnaris (FCU) transfer for radial nerve palsy using pronator teres (PT). the splint extends just proximal to the PIP joints which are left free to move. 2. 2. The palmaris longus is divided at the flexor retinaculum and sutured to the rerouted EPL.10) 1. Figure 6.10. rerouted superficial to the brachioradialis and extensor carpi radialis longus. Note: An alternative to the long arm splint is a sugar tong splint which allows limited elbow motion. The splint extends just proximal to the PIP joints to allow them full flexion range. Weeks 0 to 4 Active IP joint flexion and passive IP joint extension exercises are carried out regularly throughout the day. Elbow in 90 degrees of flexion. and then sutured as distally as possible to the extensor carpi radialis brevis. FCU and palmaris longus (PL) as motors. 3. Radial nerve palsy correction with FCU transfer Technique 1. 5.

9A. P. G. 5. In Green’s Operative Hand Surgery (D. 632–40. Burkhalter. A. C. 55A. Hastings. (1995). Omer. Mosby. 89–97. In Green’s Operative Hand Surgery (D. L. With the arm held in the same position that is maintained in the splint. Sakellarides. M. Pederson... P. Tendon transfers.. J. Bone Joint Surg. Davis. Acta Orthop. Claw-hand caused by paralysis of the intrinsic muscles. 725–32. and Thompson. E. Rowntree. R. 1076–80. Green. Burkhalter. (1987). C. 20. C. 68–79. N. R. Beach. II and McCollam. A clinical-experimental investigation in normal and anomalous innervation. 75–99. Thompson. Opposition of the thumb. Bone Joint Surg. 87. Kaplan. E. J. B. 2. Churchill Livingstone.. and Linscheid. P. M. Combined flexion (i. This will result in slight wrist extension. In Rehabilitation of the Hand: Surgery and Therapy (J. (1938). 1. 1–3. 765–78.. 192–9. Paralytic claw fingers – A graft tenodesis operation. 1481–96. R. 24. A. 12B. (1973). N. In Management of Peripheral Nerve Problems (G. Conolly. Jr. Bone Joint Surg. (1949). J. E. M. G. 104. 275–80. Hotchkiss and W. Week 6 onwards The patient can now discard the splint. H. E. Activities are gradually upgraded to provide increasing resistance with the aim of restoring power to the hand. Churchill Livingstone. E. Parkes. the patient is asked to gently pronate the forearm. Modified pulley for opponens tendon transfer.. J.. Preoperative and postoperative management of tendon transfers after radial nerve injury. (1966). (1999).. Hand Surg. S. B. H.. (1942).. 19A. Hunter. and M. simultaneous flexion of all three finger joints) can be commenced.. J. J. C. Bunnell. Median nerve palsy. 1497–525. 39A. Camitz palmaris longus abductorplasty for severe thenar atrophy secondary to carpal tunnel sundrome.. D. eds) pp. Suppl. (1970). J. The patient is then asked to gently flex the wrist. Stanley. 52A. Callahan. and Barton. D. Bone Joint Surg. Christensen. Churchill Livingstone. Mulroy. (1993). R. 215–249. Bone Joint Surg. (1999). B.. C. P. 14–18. W. This action will result in simultaneous finger and thumb extension. eds) pp. R. In Atlas of Hand Surgery (W. C. 178–9. A simple surgical procedure for its correction. Churchill Livingstone. L. T. Terrono. W. E. and Millender. A modified operation for opponens paralysis. N. . C. Hand Surg. J. Extensor indicis proprius opponensplasty. L. Saunders. eds) pp. Hand Surg. J. ed. Bone Joint Surg. J. Bone Joint Surg. C. Reynolds. A. A well-motivated patient should have good control of function by the 3rd month although many patients take as long as 6 months to gain optimal recovery. T. (1942). (1984). R. Hand. J. 777–86. B. Hotchkiss and W. J. Spinner. Rose. In Green’s Operative Hand Surgery (D. Green. Surgery of the intrinsic muscles of the hand other than those producing opposition of the thumb. M. W. Pederson. eds) pp. J. P. Citron. G. Green. Green. The patient can use the hand for light daily activities which will encourage spontaneous muscle action and improve finger flexibility. 26. 31B. E. Radial nerve palsy. there is a high incidence of tendon adhesion along the course of the transfers. 18A. H. N. W. Normal and anomalous innervation patterns in the upper extremity. E. 204–6. Anomalous innervation of the hand muscles. Mannerfelt. J. Firm oil massage and silicone gel compression are therefore important aspects of management. 753–63.. 209–19. (1957).Tendon transfers 81 following active exercises are performed in sequence and repeated 5 to 10 times. (1994). P. T. Early tendon transfer in upper extremity peripheral nerve injury. R. T. J. H. Opposition of the thumb: an anatomic and biomechanical study of tendon transfers. Cooney. Callahan. and Taylor. P. J. Hotchkiss and W.e. (1973). S. Hand Surg. Bunnell. 505–10. 6. In Rehabilitation of the Hand: Surgery and Therapy (J. 1526–41. Studies on the hand in ulnar nerve paralysis. Zancolli.. Hunter. (1980). (1999). References Brand. Mosby.) pp. D. Tendon transfer in partially anaesthetic hands. J. These manoeuvres are repeated until the patient is able to demonstrate spontaneous use of the transfers. Active wrist flexion exercises are emphasized to overcome soft tissue tightness on the dorsum of the forearm and hand. Warren.. D. Pederson. Flexor digitorum superficialis lasso tendon transfer in isolated ulnar nerve palsy: a functional evaluation. Mackin and A. eds) pp. L. B. Omer Jr. W. N. J. Relative tension and potential excursion of muscles in the forearm and hand. 269–84.. (1997). eds) pp. and Brown. (1995). Orthop. Ulnar nerve palsy.. Clin. S. (1974). Mackin and A. Hand Surg. Following this procedure. Preoperative and postoperative management of tendon transfers after median nerve injury. and Spinner. (1981). Scand.

eds) pp. Tendon transfers for median and ulnar nerve paralysis. R.. Williams & Wilkins. North Am. North Am. W. J. Flynn. 817–46. G. 1. Omer Jr. 715–28. Hunter. E. Mechanics of tendon transfers. In Hand Surgery (J. Jr.. B. W. Techniques in hand surgery (abstract). The technique and timing of tendon transfers. 907. (1995). M. E. eds) pp. Tendon transfers for reconstruction of the forearm and hand following peripheral nerve injuries. Further reading Bell-Krotoski. In Management of Peripheral Nerve Problems (G. Pulvertaft. P. Preoperative and postoperative management of tendon transfers after ulnar nerve injury. E. 243–52. . Orthop. Bone Joint Surg.. Tendon transfers in the forearm. In Rehabilitation of the Hand: Surgery and Therapy (J. ed.82 The Hand: Fundamentals of Therapy Brand. G. 5. (1970). W. Mosby. Callahan. Orthop. W. Mackin and A. Callahan. (1980). D. E. eds) pp. In Rehabilitation of the Hand: Surgery and Therapy (J. D. (1995). 42A. J. G. J. P. Spiner. Saunders. and M. Omer. Brand. 447–454. J. E. Mackin and A. Mosby. M. (1960). 729–51. Hunter. P. Brand. Clin. (1974). 189–200. Jr. E.) pp. Omer. (1975). Clin.

g. Cumulative trauma Repetitive muscle contraction and poor body posture can contribute to nerve injury (Lundborg and Dahlin. enzymes. As the peripheral nerves course from their respective cervical roots to the hand. or there may be a narrowing of the tunnel from post-traumatic fibrosis or osteoarthritis. A thorough assessment of the . alcoholism. they can be subject to compression in a number of specific anatomical tunnels and spaces. 3.g.g. Double crush phenomenon The various substances synthesized by the nerve cell body. Causes of nerve compression 1. are necessary for the normal function and survival of the axon. Where synthesis or transport of these substances is disrupted. 1988). Axoplasmic transport mechanisms are then responsible for returning breakdown products in a proximal direction. can cause nerve compression (Lakey and Aulicino. 1981). the axons will be more vulnerable to compression. Even minor nerve injury will affect the quality of the axoplasm and the rate of its flow. These substances travel along the axon in a distal direction. polypeptides. These include: diabetes. 1985). aberrant muscles in the carpal tunnel. e. 2. Hormonal changes relating to pregnancy and menopause can predispose to carpal tunnel syndrome. a space-occupying lesion such as a ganglion or tumour.g. ‘Elvey’s test’ (Elvey. Medical conditions Compression neuropathies can be associated with a number of medical conditions which influence peripheral nerves and thus render them more susceptible to compression syndromes. e. which raises the intrafascicular pressure throughout the body (Myers and Powell. This disruption of axoplasmic flow will increase the susceptibility of the nerve to compression at sites proximal and distal to the original site. hypothyroidism and exposure to industrial solvents.7 Peripheral nerve entrapment This chapter deals with compression neuropathies at and below the elbow that have been deemed exclusive of more proximal causes such as cervical nerve root compression or thoracic outlet syndrome. A coexistent cervical lesion is one of the reasons for persistent residual symptoms following carpal tunnel release and some patients may require a proximal as well as distal decompression (Mackinnon and Dellon.. 1986). Change in tunnel dimensions Compression may be due to an increase in the contents of the tunnel e. A brachial plexus screening test should therefore form part of the routine examination for peripheral nerve compression in the upper extremity. Congenital anomalies. etc. free amino acids. 1973) or ‘multiple crush’ syndrome. 1989). This is referred to as ‘double’ (Upton and McComas. e.

Sensory evaluation – using the Semmes–Weinstein monofilaments. The median nerve is the softest and most volar structure in the carpal tunnel. These tests include electromyography (EMG) and nerve conduction velocity (NCV) studies. the thick aponeurosis between the thenar and hypothenar muscles. the deep forearm fascia. X-ray examination – to exclude osteoarthritis of the carpal tunnel or deformity following trauma. The dorsum (or floor) of the tunnel is bounded by the bones of the carpus. clumsiness. It must be borne in mind that light touch perception can be normal when paraesthesia is present. 4. 7. Clinical examination including provocative tests. i. paraesthesia. numbness. At the distal edge of the TCL. Diagnosis of peripheral nerve compression Assessment of peripheral nerve pathology includes the following: 1. e. and radially to the scaphoid tubercle and the beak of the trapezium. the median nerve normally divides into 6 branches: Transverse carpal ligament Palmaris longus Median nerve Volar Guyon’s carpal space ligament Flexor carpi radialis Flexor pollicis longus Carpal tunnel Median nerve compression Carpal tunnel syndrome Compression of the median nerve in the carpal tunnel. (ii) flexor pollicis longus tendon and (iii) the eight flexor tendons of the four digits. The carpal tunnel proper contains: (i) the median nerve. Proximally.1. there are two tunnels (or canals) and one space. Electrodiagnostic tests – while not always entirely reliable. 3. rigid fibrous sheet which is attached ulnarly to the pisiform bone and hook of hamate. temperature or texture of the skin or nails. is by far the commonest of all peripheral nerve entrapments. Diagrammatic transverse section through the midcarpus showing the transverse carpal ligament. 2. History of the condition – and the activities that cause or aggravate symptoms. Anatomy The carpal tunnel is a rigid osteoligamentous canal.1). Distally. 3.84 The Hand: Fundamentals of Therapy work environment and postural habits may help determine the cause(s) of symptoms. At the wrist. It is overlain with the proximal antebrachial fascia. 6. It lies directly beneath the TCL and is superficial to the nine digital flexor tendons. the tendon of palmaris longus and the distal palmar fascia. Figure 7. Guyon’s space contains the ulnar artery and ulnar nerve (Fig. . 5.e. the two tunnels (or canals) and Guyon’s space containing the ulnar nerve and artery. the elbow flexion test for cubital tunnel syndrome. 2. electrical studies may be the only objective means of assessing nerve entrapment. 3. Sensory – pain. The second canal contains the tendon of flexor carpi radialis. The transverse carpal ligament (TCL). Clinical features The clinical features of nerve compression can include the following: 1.g. MRI or CT scan. a thorough assessment of work habits is especially important if an occupational aetiology is suspected. Motor – weakness. The FR has three components: 1. 2. carpal tunnel syndrome (CTS). Phalen’s test for carpal tunnel syndrome. This is a threshold test which is more likely to determine a gradual deterioration in nerve function where cortical organization remains intact. Autonomic – changes to colour. They can also help confirm the existence of more proximal sites of entrapment. The flexor retinaculum (FR) forms the roof of the carpal tunnel and extends from the distal radius to the bases of the metacarpals. The TCL is a thick (2–4 mm). Imaging – such as ultrasound.

Peripheral nerve entrapment 85 Three proper digital nerves Recurrent motor branch Palmar cutaneous branch Median nerve Two common digital nerves Ulnar nerve Transverse carpal ligament usually precede weakness and wasting by weeks or months. Phalen’s (wrist flexion) test is performed with the forearm held vertically in the air while maintaining the wrist in flexion for a period of 60 seconds. pain and paraesthesia in the median nerve distribution of the hand.g. . Variations in the palmar cutaneous branch are also common (Siegel et al. The transverse carpal ligament is a thick fibrous sheet attached ulnarly to the pisiform and hook of hamate. 3. It occasionally has a high or low division into its various branches and there may be a persisting median artery. The recurrent motor branch. pain and paraesthesia are most distressing at night. The median nerve lies directly beneath the TCL and normally divides into six branches at the distal edge of this ligament. The fingers may feel swollen and the whole arm heavy. symptoms may also involve the ring and little fingers. Phalen’s test (wrist flexion test) Figure 7. 1. Clinical assessment Two commonly used provocative tests to help in the clinical diagnosis of CTS are Phalen’s test and Tinel’s sign. Two common digital nerves (one to index/ middle and one to middle/ring) (Fig. and radially. The patient usually attempts to relieve these symptoms by hanging the arm over the side of the bed or shaking the hand. 7. the motor branch may be extraligamentous. both subjective and objective.2.3. Median nerve anomalies are common. There are also variations in the course of the median nerve itself. There is often associated clumsiness and weakness of pinch. This is related to vascular stasis caused by inactivity and pressure on the median nerve from wrist flexion or lying on the arm. This is referred to as ‘waking numbness’. transligamentous or subligamentous and may arise from the volar.. Because of communication between the median and ulnar nerves. 2. This test is performed with the patient holding the forearm vertically in the air and allowing the wrist Figure 7. The painful burning. Characteristically. to the scaphoid tubercle and beak of trapezium. Sensory changes. While these tests are not absolutely diagnostic. e. 1993). they are positive in about two-thirds of patients with this syndrome.2). Patient presentation The patient usually presents with numbness. The most common pattern of the motor branch is extraligamentous and recurrent. radial or ulnar side of the median nerve. 1. numbness or tingling sensations may radiate up the arm to the shoulder or neck where there may be restriction to longitudinal glide of the nerve. Three proper digital nerves (two to the thumb and one to the index finger).

86 The Hand: Fundamentals of Therapy Causes of carpal tunnel syndrome The causes of CTS are many and varied. Intermittent day use is recommended for patients whose symptoms are also present during the day. Postural assessment in relation to the work environment or leisure activities. excessive alcohol consumption and tobacco use. 5. infection within the tunnel. Tinel’s sign The Tinel’s manoeuvre involves gentle tapping over the median nerve at wrist level. the test is considered to be positive. Early These patients have a history of recent onset and intermittent symptoms of numbness and paraesthesia. Raynaud’s disease. vibration and temperature of work environment. Weakness of lumbrical action to the middle finger may occasionally be seen. thrombosis of an anomalous median artery or iatrogenic injection injury of the median nerve. which is not always present in CTS. Occupational factors can include repetitive force (particularly where fingers and wrist are flexed simultaneously). in more established cases. Again.4. The reverse Phalen’s test may be positive when the wrist flexion test is negative. These may include: discoloration of the skin. This can be tested by forcible tip-to-tip pinch between the thumb and ring finger. Lifestyle factors are also believed to play an important role in the incidence of CTS. For patients who have had Figure 7. posture. There can be an acute onset of CTS following wrist trauma. if this produces symptoms. The reverse Phalen’s test places the median nerve on the stretch and may elicit a positive response when the wrist flexion test is negative. Stages of compression 1. prolonged endoneurial swelling with resultant fibrosis can result in permanent sensory and motor loss. diabetes. especially abductor pollicis brevis. 2. The fingers and thumb remain relaxed. 5. This category of patients shows the best response to conservative treatment measures which include: 1. can be assessed with monofilaments which may detect loss of light touch or. 4. Autonomic findings As the median nerve transmits most of the sympathetic nerve supply to the hand. This position is held for 60 s and is considered positive if numbness and paraesthesia are elicited during this time (Fig. brittleness or shedding. to fall into full flexion. myxoedema and acromegaly. . Corticosteroid injection into the carpal tunnel (this helps reduce inflammatory oedema around the nerve). Wrist splinting The wrist support is used only at night if there are no day symptoms. 3. thus extending the wrists and placing the median nerve on the stretch (Fig. 4. Wrist splinting in neutral or slight extension (the carpal tunnel has maximum capacity in these positions).3).. Nerve gliding exercises. The reduced epineurial blood flow leads to impaired axonal transport. The palms of the hands are placed together with the elbows raised. menopause. Whilst these effects can be reversed in the early stages. rheumatoid disease. disorder of sweating in the hand and fingers or nail changes such as fragility. 1992). Assessment of motor function Abnormal motor signs include weakness of the thenar muscles. Semmes–Weinstein monofilaments Sensory impairment. Metabolic and endocrinal causes can include: pregnancy. 2. 7. 7. 3. There is an ischaemic factor in many compression neuropathies (Gelberman and Szabo. there may also be abnormal autonomic findings.4). 1986). loss of protective sensation. Modification of work practices and work environment where indicated. These factors include: obesity (Nathan et al.

1991. Nerve gliding exercises Totten and Hunter (1991) have developed a series of nerve gliding exercises for the brachial plexus and the median nerve at the carpal tunnel. the wrist is extended while finger extension is maintained..Peripheral nerve entrapment 87 a corticosteroid injection. should resolve after several hours (Fig.6). numbness or pain following the gliding exercises should not take more than a few hours to resolve. 7(3). 1 2 3 Figure 7. It is preferable to ‘underperform’ the exercises rather than to perform them too vigorously and exacerbate symptoms. 505. Symptoms of tingling.5). Some trial and error is usually necessary to establish the appropriate level of exercise. determined that the greatest excursion occurred proximal to the carpal tunnel at the wrist. Gentle brachial plexus gliding exercises can be used in the workplace as part of a prevention/ treatment strategy that also incorporates assessment/modification of postural and work habits. 7. to minimize nerve-tendon adhesions. Median nerve gliding exercises can be performed as part of a conservative treatment programme or following open or endoscopic carpal tunnel decompression.) These gliding exercises address the entire length of the nerves. The head is in the midline position. the wrist is rested continuously for a period of 2 weeks (Fig. A study by Wilgis and Murphy (1986) on the longitudinal excursion of peripheral nerves. The exercises can be performed with the patient sitting or lying supine. a gentle stretch is applied to the thumb. the fingers extend and the thumb lies in neutral beside the index finger.5. A. P. from proximal to distal. This manoeuvre is far more likely to produce an irritable response and should therefore be performed very cautiously. 7. Position 5: with the forearm still in supination. the shoulder is adducted and the elbow is flexed to 90 degrees (Fig. Brachial plexus gliding exercises 4 5 Figure 7. 7. Position 2: the wrist remains in neutral.6. When this point is reached. and Hunter. the wrist in neutral extension and the fingers and thumb are flexed. Early symptoms of CTS are managed with conservative measures that include a wrist splint to maintain the wrist in neutral or slight extension. Hand Clin. the forearm is supinated. The manoeuvre is performed to the point where slight tension is produced. Position 4: the wrist is returned to neutral extension and with the fingers and thumb also in neutral extension. as with the above exercises. (Redrawn with permission from Totten. methodical manner with 5 to 10 repetitions every 1 to 2 hours. the patient is asked to back off slightly to ease these symptoms. The median nerve gliding exercises can be used for conservative management of CTS or postoperatively. Intermediate Patients in this category report almost constant numbness and paraesthesia and are candidates for nerve decompression. The exercise sequence is performed in a slow. . Position 3: while the thumb remains in the neutral position.7). Position 1: the forearm is in neutral rotation. Therapeutic techniques to enhance nerve gliding in the thoracic outlet and carpal tunnel syndromes. 2. J. M. Symptoms are often not evident for several hours after the exercise and. this usually manifesting as a slight pull or some change to sensibility.

and as far as the level of the thumb web space. Position 7: Lateral cervical flexion to the opposite side is the final component of this manoeuvre. Any adhesions of the median nerve to surrounding flexor tenosynovium are freed by careful dissection. The aim of surgery is to increase the dimensions of the carpal tunnel by releasing the transverse carpal ligament and its fascial extensions.) 3. (Redrawn with permission from Totten.. Late These patients have usually had longstanding symptoms. The skin incision is made 2–3 mm ulnar to and parallel with the thenar crease and extends from just proximal to the wrist crease proximally. 1991. A. The obvious advantage of the open technique is good visualization which allows identification of anatomical anomalies. Where appropriate.. The brachial plexus programme is as follows: Position 1: the head is laterally flexed to the affected side with the elbow. J. Therapeutic techniques to enhance nerve gliding in thoracic outlet and carpal tunnel syndromes. 1989). and Hunter. these patients are offered an opposition transfer to enhance pinch grip function. Position 3: the hand is moved across the chest and down to the hip level. The division is not complete until the median nerve can be seen throughout its course in the canal. 7. there may be permanent sensory impairment and thenar wasting because of the degree of neural fibrosis. care is taken to preserve the small cutaneous nerves to avoid incisional tenderness. 7(3). . The TCL and related fascia are divided. The skin is closed with interrupted fine sutures. Position 4: the patient gradually extends the elbow and increasingly abducts the shoulder into positions 5 and 6. This means a reduced risk of iatrogenic injury. 505. P. wrist and fingers of the affected side in flexion. During incision. distally (Fig.8). Hand Clin. Position 2: the head comes to the neutral position. Even after decompression.7. 1. Surgery Surgery to decompress the tunnel is indicated where conservative measures have failed to relieve symptoms. The carpal tunnel floor is inspected for ganglia or bony spurs.88 The Hand: Fundamentals of Therapy 1 2 3 4 5 6 7 Figure 7. Studies have shown that the average increase in volume of the tunnel following decompression is 24 per cent and that the tunnel is converted from an oval to a circular shape (Richman et al. M. Open decompression Decompression of the carpal tunnel has traditionally been performed as an open procedure.

Light massage. 1993). palmar fasciitis and chronic regional pain syndrome resulting from injury to the palmar cutaneous branch of the nerve. The advantages of endoscopic release over open decompression include a faster return to activity and more rapid return of grip strength. 7. Postoperative management Exercise Figure 7. Pillar pain remains a problem that is associated with both the open and endoscopic techniques of decompression. shoulder and elbow movements are commenced immediately to maintain longitudinal glide of the median nerve. Specific median nerve gliding exercises are performed as for conservative management of CTS. has not been fully eliminated with endoscopic decompression. Results Relief of pain following surgery should be immediate. This complication can lead to disability far greater than the original disorder. using oil or cream. hypertrophic scarring. .Peripheral nerve entrapment 89 postoperative complications include: haematoma (from damage to the superficial palmar arch). (1995). Nonetheless. Thumb and finger movements are performed within the postoperative cast. Immediate The wound is dressed and supported with a light compression bandage. Nerve conductivity improves slowly over 1 to 2 years. palmar pain/hypersensitivity from the entrapment of cutaneous nerves within the scar. 2. The area should be washed and dried thoroughly and be free of oily residue prior to application of the gel. The hand is rested in neutral extension for the first 1 to 2 postoperative days..8. The procedure does. usually associated with the open technique. carry a greater risk of iatrogenic injury because the median nerve is not actually seen during the procedure. Palm tenderness. however. Neck.9). The gel is held in place with Tubigrip stockinette of appropriate tension (Fig. Skin incision for open carpal tunnel decompression. Gentle active wrist movements are commenced on the 2nd or 3rd postoperative day. simultaneous wrist and finger flexion is avoided as this position makes the tendons most vulnerable to bowstringing. Complications of surgery Intraoperative complications include injury to the median nerve trunk or its branches. Earlier concerns regarding the risk of tendon bowstringing with early mobilization have been dispelled (Nathan et al. Most postoperative scars resolve uneventfully within 4 to 6 weeks after surgery. oedema or infection. is usually well tolerated and should be performed 4 to 6 times a day by the patient as part of a home programme. Scar management is then commenced. Raised or persisting scar is managed with silicone gel. Scar management Sutures are usually removed about 10 days after surgery. All exercises are performed gently and slowly every 2 h within the limits of discomfort. The two best known techniques are the two-portal technique of Chow (1994) and the single portal technique of Agee et al. Later complications can include: persisting hand weakness. pillar pain. Endoscopic carpal tunnel decompression The past decade has seen the introduction of endoscopic carpal tunnel release as an alternative surgical procedure to open carpal tunnel release. however. relief of numbness or weakness may be slow and incomplete.

11). Compression of the median nerve at more proximal locations Pronator syndrome The median nerve can be constricted just above the elbow by the ligament of Struthers. Pillar pain following carpal tunnel decompression (open or endoscopic) can be relieved with supportive wrist strapping. Hypersensitive scar is covered with Opsite Flexifix film to reduce discomfort. at the elbow by the lacertus fibrosis and in the upper forearm. The area of application has been dotted for identification. Heavier activities are avoided for 2 to 3 months. The therapist should remain alert to a sudden increase in pain and hypersensitivity which may herald the onset of chronic regional pain syndrome. colour changes (mottling) and excessive sweating.11.10. . Return to activity Light daily activity can be commenced 2 to 3 weeks after surgery. It is addressed with supportive wrist strapping or splinting which usually alleviates discomfort and gives the patient greater confidence in using the hand (Fig.e. and can significantly hamper hand function.9. Hypersensitivity Where scar sensitivity is a problem. i. Persisting scar is managed with silicone gel that is held in place with Tubigrip support stocking. Figure 7. Silicone gel can be applied over the Opsite where necessary (Fig. Other signs and symptoms associated with this condition include persisting hand oedema. between the thenar and hypothenar eminences.10). between the two heads of pronator teres and under the fibrous arch of flexor superficialis. Patients are advised that the return of maximum grip strength can take some months to achieve.90 The Hand: Fundamentals of Therapy Figure 7. This usually manifests as an ache in the area of decompression. Silicone gel can be used over the film. 7. 1997). It should be suspected if pain and paraesthesia in the cutaneous distribution of the median nerve are associated with forearm pronation rather than the usual night Figure 7. Pillar pain Some patients are troubled by pillar pain for several months following decompression (Ludlow et al.. Hypersensitivity that is troublesome enough to interfere with the exercise programme is managed with transcutaneous electrical nerve stimulation (TENS). Pronator syndrome is rare (representing less than 1 per cent of peripheral neuropathies) and can result from repetitive use of the arm. a layer of Opsite Flexifix is applied over the sensitive area. 7.

In the palm. Outcome following decompression for complete lesions is superior to that for partial lesions involving only the thumb and index finger (Werner. . Figure 7. 1989). Ulnar nerve compression The commonest sites for compression of the ulnar nerve are at the elbow (cubital tunnel syndrome) or in Guyon’s canal at the wrist (ulnar tunnel syndrome). the forearm in slight pronation and the wrist in slight flexion.12). Percussion test at the cubital tunnel A positive Tinel’s test when the nerve is percussed over the medial epicondyle can indicate entrapment at this level. The elbow flexion test is used in the assessment of cubital tunnel syndrome. This test on its own is not diagnostic as almost a quarter of asymptomatic people have a positive response to this test. Elbow flexion test (Wadsworth. Patient presentation The patient usually presents with paraesthesia or numbness in the little finger and the ulnar half of the ring finger. 1977) This test is analogous to Phalen’s wrist flexion test for carpal tunnel syndrome.Peripheral nerve entrapment 91 manifestations of carpal tunnel syndrome. False positives can occur in 25 per cent of the population (Fig. 2. Where conservative measures fail. the median nerve is explored and released. This position relieves pressure and traction on the median nerve. Clinical assessment 1. posterior to the medial epicondyle of the humerus (where it can be palpated with ease) and into the forearm between the heads of the flexor carpi ulnaris muscle. Anatomy The ulnar nerve passes from the flexor to the extensor compartment in the upper arm through an opening in the intermuscular septum. Percussion of the median nerve at this level may cause tingling and paraesthesia. Anterior interosseous syndrome This syndrome also represents less than 1 per cent of all peripheral neuropathies. Fifty per cent of patients with pronator syndrome will respond to conservative treatment including modification or cessation of aggravating activities and the use of a removable long arm splint which maintains the elbow in 90 degrees of flexion. An incomplete syndrome can manifest as weakness of FPL and FDP to the index without involvement of pronator quadratus. firm or enlarged. 7. While there is rarely wasting of the intrinsic hand musculature in the early stages of compression. lateral to the pisiform bone and medial to the hook of hamate. It then passes through the cubital tunnel at the elbow. The most frequent cause of this syndrome is a fibrous band(s) in the pronator teres muscle. The pronator teres muscle can be tender. it divides into superficial and deep terminal branches. It involves holding the elbow in maximum flexion with the forearm in supination and the wrist in neutral to avoid confusion with Phalen’s wrist flexion test for carpal tunnel syndrome. the sensory symptoms are often accompanied by a weak grip. The position is held for two minutes and the test is considered positive if symptoms of numbness and paraesthesia in the ulnar nerve distribution are elicited during this timeframe. Sensibility is unaffected. Anterior interosseous syndrome is characterized by loss of function of FPL and FDP to the index (sometimes FDP to the middle finger and pronator quadratus). It enters the hand by passing over the flexor retinaculum. Palpation of the median nerve in the proximal forearm produces pain.12.

Patients are instructed in ulnar nerve gliding exercises (Totten and Hunter. or subluxation of the nerve over the medial epicondyle during elbow flexion. X-ray of the elbow This is useful for patients with arthritis or a history of trauma to the elbow.g. 1991).e. e. 7. and presence or absence of nerve subluxation. Prolonged elbow flexion during the day should also be avoided (Fig. Simple decompression This procedure involves releasing the arch of the FCU origin so that unrestricted movement of the 6. soft tissue structures. Approximately half of all patients with cubital tunnel syndrome will improve spontaneously. Cubital tunnel syndrome Cubital tunnel syndrome is the second most common nerve compression after carpal tunnel syndrome.92 The Hand: Fundamentals of Therapy 3. These exercises are performed every 1 to 2 hours with 5 to 10 repetitions. Choice of procedure will depend upon the patient’s age (in the older patient. in the absence of motor changes) can be managed with night splinting that holds the elbow joint in 30 to 45 degrees of flexion. Mild. the most common cause of cubital tunnel syndrome (with the exclusion of trauma). e. flexor digitorum profundus to the ring and little fingers and the intrinsics should be assessed. 7. Some relief of symptoms should be apparent within 3 weeks if conservative management is having any effect. the ulnar nerve is predisposed to compression because of anatomical peculiarities in the region of the elbow (Feindel and Stratford. At this level. Where this is not the case. Semmes–Weinstein monofilament test Decreased sensibility over the dorsal ulnar aspect of the hand would indicate that the lesion is proximal to the wrist as the dorsal cutaneous branch of the ulnar nerve branches proximal to Guyon’s canal. Electrodiagnostic studies These will help establish the diagnosis and will help determine the level of the lesion. intermittent sensory symptoms of cubital tunnel syndrome can be managed with night splinting that prevents acute elbow flexion during sleep. Procedures include: 1. tumour or ganglion. intermittent sensory symptoms (i. although there are no data pointing to work as a risk factor.14). Activities involving repeated elbow flexion and extension can aggravate cubital tunnel syndrome. constricting fascial bands.g. Oral anti-inflammatory medication is sometimes used in conjunction with splinting. 4. 1958).13).13. Conservative management 5. This will prevent acute elbow flexion when the cubital tunnel is at its narrowest. Mild. It must be remembered that the median nerve can contribute to innervation of the intrinsics via a Martin–Gruber anastomosis and that FCU and FDP are spared if their innervation is proximal to the cubital tunnel. is a shallow canal with partial anterior subluxation of the ulnar nerve during elbow flexion. Surgical procedures for cubital tunnel syndrome There are a number of surgical options for the management of this syndrome. the nerve is vulnerable to iatrogenic injury during transposition). surgical options are considered (Fig. spurs or cubitus valgus. Muscle assessment Flexor carpi ulnaris. Cubital tunnel syndrome may be caused by: bony abnormalities. Figure 7. . pathology. In patients under 40 years of age.

e. the elbow is protected in a sugar tong splint which immobilizes the forearm . the patient is asked to back off slightly. A soft compressive dressing is applied and early active elbow motion is encouraged following this procedure. Medial epicondylectomy The medial epicondyle is removed and the bone is smoothed. To maintain the integrity of the anterior medial collateral ligament. about one fifth of the width of the epicondyle.14. To protect the reattachment of the muscle mass for 2 to 3 weeks. The elbow is protected with a bulky dressing and light plaster for about 1 week. Position 2: the wrist and fingers are extended. Anterior subcutaneous transposition This procedure is indicated for anatomic lesions that interfere with or compress the ulnar nerve along its course.) nerve can occur during elbow flexion. In this procedure the ulnar nerve is not disturbed in its bed and does not undergo neurolysis. The elbow is extended and the wrist and fingers are flexed. This allows the nerve to migrate anteriorly and lie free. The procedure involves unroofing of the cubital tunnel and elevation of the flexor-pronator muscle mass at its origin. When this point is reached. Position 4: the shoulder is abducted. 3.g. The first three positions emphasize the distal ulnar nerve and begin with a position of minimal stress. Position 3: the elbow is flexed. PC. Position 5: external rotation of the shoulder is added to the previous posture. (Redrawn with permission from Philadelphia Hand Centre. the elbow extended and the wrist brought to neutral. Position 6: this position incorporates lateral cervical flexion to maximize tension. i. as it places the nerve in an unscarred bed.Peripheral nerve entrapment 93 1 2 3 4 5 6 Figure 7. The elbow is protected in flexion with a bulky dressing with plaster reinforcement for the first 10 postoperative days.e. Pennsylvania. removal of the epicondyle should be restricted to 1–4 mm. The ulnar nerve may sublux following this procedure. Philadelphia. Ulnar nerve gliding exercises used in conservative management of cubital tunnel syndrome.. 4. The nerve is moved anterior to the medial epicondyle and the muscle mass is returned to its origin and now overlies the ulnar nerve. The sequence is performed only to the point where slight tension is produced. The final three positions in the sequence focus on the proximal ulnar nerve with the distal segment in a more neutral position. Early gentle active elbow movement is commenced following this procedure. The medial intermuscular septum is then resected and the nerve is placed in the subcutaneous tissue. tumour. Sometimes a flap of antebrachial fascia is used to create a fasciodermal sling around the transposed nerve. Early gentle elbow movements can then be commenced. Anterior submuscular transposition This procedure is indicated for more severe neuropathy and is the best salvage procedure for previous procedures that have failed. Position 1: the head is in the midline and the shoulder is forward flexed and adducted. The ulnar nerve is decompressed as for simple decompression. 2. ganglion or osteophyte. anterior to the medial epicondyle. 901 Walnut St.

the elbow is flexed to 90 degrees and the wrist and fingers are flexed. Patients should avoid leaning on the elbow until tenderness has subsided. Philadelphia. If passive range of motion exercises are required. Position 5: the arm is externally rotated. Position 1: the shoulder is adducted and flexed to 90 degrees. however. PC. Gentle active elbow. (Used with permission from the Philadelphia Hand Centre. however. Pain or tenderness over the medial elbow following epicondylectomy can be addressed with a soft elbow pad if silicone gel does not provide sufficient relief. Pennsylvania). . they are done so gently and carefully so as not to exacerbate neurological symptoms. This is held in place with Tubigrip stockinette and will control oedema around the elbow. Position 6: lateral cervical flexion is added to the previous position. Following surgery. These symptoms will be present if axonal regeneration is occurring and will subside with time. forearm and wrist movements are commenced after 3 weeks. intermittent use of the long arm splint is maintained for another week or two. Raised scar is managed with silicone gel. Anterior intramuscular transposition This procedure resembles the above procedure. Position 2: the wrist and fingers are extended. Nerve gliding exercises Postoperative ulnar nerve gliding exercises are instituted as soon as active motion is allowed (Fig. Position 3: the elbow is extended. End range of elbow movement is not a priority in the first few weeks following surgery. Scar and oedema management Scar is treated with gentle oil massage which will also serve to desensitize the area. Regaining movement When active and passive movements are commenced. 5. they are commenced after 6 weeks together with strengthening exercises. the forearm in 30 to 45 degrees of pronation and the wrist in 30 degrees of flexion for a period of 3 weeks. 901 Walnut St.94 The Hand: Fundamentals of Therapy and wrist but permits a short arc of elbow movement. the ulnar nerve is placed within the flexorpronator muscle mass rather than beneath it.. the elbow is maintained in 90 degrees of flexion. Postoperative ulnar nerve gliding exercises. 1 2 3 4 5 6 Figure 7. the elbow is flexed to 90 degrees and the wrist and fingers are in gentle flexion.15.15). Position 4: the shoulder is abducted. 7.

it is observed for 2 to 3 months provided that there are no signs of deterioration. 7. Night pain is not uncommon. Forceful forearm rotation is avoided during this time. Patient presentation The patient may present with wrist pain and associated numbness. weakness is the main feature of these syndromes. conservative management is trialled. If conservative measures fail to provide relief of symptoms. it should not be delayed for too long because of the risk of permanent muscle weakness. Conservative management Where an obvious cause of compression cannot be found. 2. and non-steroidal anti-inflammatory medication. If surgical decompression is considered necessary. the ulnar nerve is released within Guyon’s canal and is explored from the distal forearm into the palm.Peripheral nerve entrapment 95 Hypersensitivity Hypersensitivity resulting from scar or axonal regeneration is addressed with a layer of Opsite Flexifix. If the syndrome appears to be a postoperative neurapraxia. The patient complains of a weakness of finger and wrist extension and some associated pain. The patient typically complains of a deep. Symptoms of ulnar carpal syndrome can sometimes be provoked by sustained wrist hyperflexion or hyperextension.g. 1. This involves wrist splinting in neutral or slight extension. motor or mixed. This syndrome is often related to work activities that . tingling or burning that radiates into the ring and little fingers. or muscle anomalies. Clinical assessment This includes palpation of tender areas (e.g. X-ray of the elbow to rule out dislocations or fractures. Where there has been excision of the hook of hamate. aching pain on the lateral aspect of the elbow. Muscle testing of the intrinsic hand musculature is carried out. Weakness of the intrinsic musculature can occur and can progress to atrophy if the compression is not relieved. Ulnar tunnel syndrome The ulnar nerve courses through Guyon’s canal between the volar carpal ligament and the transverse carpal ligament. Investigative tests include: EMG. fractures of the hook of hamate. entrapment at this level may manifest as purely sensory. As the PIN is purely a motor nerve. e. modification of work activities where indicated. Posterior interosseous nerve syndrome This syndrome may have an acute presentation following trauma or there may be a gradual and painless loss of function due to a lipoma or ganglion at the elbow. Depending on the precise location of the compression. Radial tunnel syndrome This syndrome is a pain condition where weakness features secondarily. Causes The commonest non-traumatic cause of ulnar carpal syndrome is a ganglion arising from the triquetrohamate joint. The nerve is percussed for presence of Tinel’s sign and sensibility is assessed with Semmes–Weinstein monofilaments. Aftercare The wrist is supported for the first 10 postoperative days. Treatment Exploration of the nerve is indicated in the case of a space-occupying lesion or long-standing weakness. Other causes include bony lesions. Recovery following surgery can take 12 to 18 months. over hook of hamate) and checking for the presence of swelling or a soft tissue mass.16). MRI or ultrasound to exclude ganglia. Radial nerve compression Two distinct syndromes are seen at the elbow level where the posterior interosseous nerve (PIN) passes deep to the fibrous arch (arcade of Frohse) and then between the two heads of the supinator muscle itself. Silicone gel can be used over the Opsite. palmar tenderness may persist and should be managed with silicone gel compression. Radial nerve gliding exercises can be performed as part of the conservative management (Fig.

splinting and work modification are trialled prior to surgical neurolysis. does not progress to muscle palsy. Treatment Conservative measures such as local steroid injection. Grand Rapids. In the case of radial tunnel syndrome. Symptoms are aggravated by passive forearm pronation with the wrist flexed and active forearm supination with the elbow extended. This latter syndrome is also usually associated with swelling over the first dorsal compartment. The diagnosis is confirmed if there is relief of symptoms following a local anaesthetic into the radial tunnel. (Redrawn with permission from a home programme form used by Spectrum Health Rehabilitation and Sports Medicine Services. Another provocative manoeuvre involves extending the elbow and digits fully with the wrist in neutral and applying firm pressure to the dorsal aspect of the proximal phalanx of the middle finger. Radial tunnel syndrome can coexist with lateral epicondylitis with which it can be confused. Position 5: the shoulder is extended while wrist flexion is maintained. If this results in pain in the proximal forearm. The sensory nerve can be compressed in the forearm between the tendons of extensor carpi radialis longus and brachioradialis as the forearm is pronated. the test is considered positive. Symptoms are exacerbated by wrist movement or tightly pinching the thumb and index finger together. Michigan. Patients complain of pain. into the forearm. Position 4: the patient adds lateral cervical flexion to the previous posture.) involve repetitive forceful elbow extension or forearm rotation. These manoeuvres are performed against resistance.16. radial nerve gliding exercises and a splint that maintains a position of forearm supination and wrist extension. Radial nerve gliding exercises. . Position 2: the shoulder is depressed. bracelets or sporting straps or from repetitive activity. Treatment Conservative treatment is always trialled first because this syndrome. tenderness will be distal to the lateral epicondyle.96 The Hand: Fundamentals of Therapy 1 2 3 4 5 Figure 7. Wartenburg syndrome (or superficial radial nerve compression syndrome) Neuritis of the superficial branch of the radial nerve can result from compression by watchbands. Position 1: the patient stands with the body in a relaxed posture. Conservative treatment involves rest. Position 3: the arm is internally rotated and the wrist is flexed. This syndrome can be difficult to distinguish from de Quervain’s syndrome which is characterized by pain at the radial styloid process which radiates down the thumb and proximally. numbness or tingling over the dorsal radial aspect of the hand. unlike the PIN syndrome. anti-inflammatory medication.

266–9. L. Osterman. A. and Szabo. G. (1986). 20A. M. P. D. 15(4). 124. B. R.. Mobilization of the Nervous System. Bell-Krotoski.. 18B. 18A. G. Peimer. 75(A).. C. 359–62. Br. Int. and Powell. L. Nathan. 1854–78. (1990). Martin. ed. The external compression syndrome of the ulnar nerve at the cubital tunnel. 182. (1993). Lundborg. Anomalous muscles associated with compression neuropathies. 193–7. D.. M. A. 144. Pressure effects on human peripheral nerve function... J. E. B. (1988). Millesi. R. L.. 1. R. eds) Churchill Livingstone. (1991). M. SpringerVerlag. H. and McComas. Phys. and Dahlin. Hand Ther. Hand Clin. Lippincott. Twoportal technique. (1996).) pp. and Sybert.) pp. In Aspects of Manipulative Therapy (E. Upton. J. R. E. 405–6. Churchill Livingstone. C. (1994). Gelberman. 19–28. Brachial plexus tension tests and the pathoanatomical origin of arm pain. M. Clinical results. et al. Further reading Amadio. Myers. L.. Rozmaryn. (1988). C. Wilgis. Can.. Carpal tunnel syndrome: morphologic changes after release of the transverse carpal ligament. Dovelle. D. (1993). Reflections on 21 years experience with carpal tunnel syndrome. Lancet... E. The double crush in entrapment syndromes. Hand Clin. Dellon. (1997). S. 182–5. S. (1970). (1989). and Keniston. Gelberman. Kerr. R. J. S. ed. Med. J. 505. Churchill Livingstone. ed. M. The American Academy of Orthopaedic Surgeons. J.) Slack. Endoscopic versus open carpal tunnel release. Hand Surg. Instructional course lectures. The significance of longitudinal excursion in peripheral nerves.. 1211–29. Med. C. N. Pillar pain as a postoperative complication of carpal tunnel release. 40–1.. The cutaneous innervation of the palm: An anatomic study of the ulnar and median nerves. A. Peripheral Mobilization. The first carpal tunnel release? J. 761–6. Feindel. The anterior interosseous nerve syndrome.. (1977). Aust. (1992). (1989). Bone Joint Surg. The upper limb tension test: the SLR test of the arm. C.. Mackinnon. Churchill Livingstone. Occup. 1044–1050. and Urbaniak. J. A. Advances in sensibility evaluation. and Aulicino. 212(8). A. G. S. Elvey. 2(4). L. J. A. Endoscopic carpal tunnel release.. Butler. D. and Mackinnon... J. Dellon. J. H. In Operative Nerve Repair and Reconstruction (R. M.Peripheral nerve entrapment 97 References Agee. Am. Patient evaluation and management considerations in nerve compression. (1998).. 634–8. J. Endoscopic carpal tunnel release: A prospective study of complications and surgical experience. R. 171–9. R. J. (1991). 7.. Radial sensory nerve entrapment in the forearm. 189.. and Murphy.. 1. S. H. Clin. L. R. In Tissue Fluid Pressure and Composition (A. Assoc. J. E. In Nerve Compression Syndromes (R. H. and Walsh. Barton. 229.. and Meadows. Werner. 379–83.. Maitland. The gliding apparatus of peripheral nerve and its clinical significance. Rehabil. (1992). ed. K. In Physical Therapy of the Cervical and Thoracic Spine. Nerve Injury and Repair. (1977). 165–72. The gold standard (editorial). 1365–7. 11(3). Pyrek. (1973). Thieme. P. J. F... and Lessne.. Mackinnon. 87. 852–7. P. Rubenach. J.. C. 199–205. Am. Clinics in Physical Therapy 17 (R. 229. J. Rothman. (1985). (1988). 277–82. et al. 11A. A. Grant. Keniston. Kenneally. L. 10(4). A. J. 2. R. and Elvey. (1986). (1995)... Hand Clin. (1993). A. An anatomical variation of the palmar cutaneous branch of the median nerve. Hand Clin. 167–94. Davlin. J. 161–83. (1989). Med. Gelberman. Butterworth.) pp. S... G... (1994). (1986). G. H. Nathan. N. Merla. Lakey. 14A. and Dellon.. Szabo. P. (1993). A. H. Seiler.. A cross-sectional and longitudinal study involving 429 workers. Meadows. Eaton. 34. Therapeutic techniques to enhance nerve gliding in thoracic outlet syndrome and carpal tunnel syndrome. W. Wadsworth. H. Hand Ther. and Aulicino. B. Obesity as a risk factor for slowing of sensory conduction of the median nerve in industry. 13. J. R. (1958). 637–46. J. W. (1991). L. Diagnosis of carpal tunnel syndrome. J. R. L.. J. M. E. P. Double and multiple crush syndromes. Hargens. . S. 8(2). R. K.) Williams & Wilkins. J. K. D. H. Orthopaedic Rev.. T. 369. C. and Stratford. R. Hand Surg. J. P. H. Gittins. D.. Myers. H. (1981). Med. Rydevik. In Tissue Nutrition and Viability (A. Cox. (1986). Gelberman. Repetitive strain disorder. (1992).. J. Hargens. D. J. S. J. O. Surg. Hand Surg. W. (1991). 20B. A. L. 527–46. M. A. Hand Surg. Surgery of the Peripheral Nerve. Hand Surg. 10. Hand Surg. 21A. J. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. Rehabilitation of carpal tunnel surgery patients using a short surgical incision and an early program of physical therapy. J. K. Med. B. Overuse syndrome in the upper limb in musicians. ed. (1986). D. Richman. L. G. E. Phalen. Ludlow.. (1989). S. 72. Glasgow et al. Johnson. Pathophysiology of nerve compression. Double crush and multiple compression neuropathy. Siegel. Ann Hand Surg. Arthroscopy. J. R. R.. L. and Hunter. R. The role of the cubital tunnel in tardy ulnar nerve palsy. L. J. Hand Surg. 7. T. Peripheral nerve compression. Endoneurial fluid pressure in peripheral neuropathies. E.. Chow. G. and Rath. and Hurst. Hand Clin. Hand Clin. L. 8. Lundborg. Fry. (1995). C. Orthop. 9(2). Totten. Orthop.. 287–300. 10. Zoch...

18A. Feldon. and Fern. Weiss.. A. Injury to the deep motor branch of the ulnar nerve during carpal tunnel release. American Academy of Orthopaedic Surgery. A. eds) pp. G.. 27(2). P. 1038–40. Fine. and Madison. Sachar. R. L. A. (1993). (1995). and Gendreau. 421–34. E. L.. S. P. Gordon. M. K. Orthop. R. M. J. M. Carpal tunnel syndrome as a work-related disorder. R. A. J.. J. 19A. and Nalebuff. In Repetitive Motion Disorders of the Upper Extremity (S. (1994). North Am.98 The Hand: Fundamentals of Therapy Terrono. Blair and L. Multiple compression neuropathies and the double crush syndrome. Belsky. L. . (1996). 381–8. 410–5. Simpson. Hand Surg. J.. Szabo. S. Conservative management of carpal tunnel syndrome. Clin. Hand Surg..

e. these conditions can have a number of causes: anatomic anomalies. 1. the A1 pulley) which can undergo marked hypertrophy (Bunnell. 1999). thyroid conditions) or occupational factors. Whilst trauma and repetitive work can exacerbate these conditions. These conditions occur in the region of the fibro-osseous tunnels which act as fulcrums for the finger and wrist tendons. 1951).g. or viral cause. An acute inflammatory response is characterized by redness. calcific tenosynovitis (e. 8. swelling. 1944) (Fig.e. Extensor carpi ulnaris. Trigger finger/thumb and de Quervain’s disease often co-exist with carpal tunnel syndrome and epicondylitis and are far more common in women than men. Inflammatory conditions Inflammatory-type conditions can be specific to certain diseases such as: rheumatoid arthritis (proliferative tenosynovitis).8 Conditions of the wrist and finger tendons Introduction The tendons of the wrist and hand are subject to a number of disorders and conditions. 1973) and interfere with tendon glide. . Infective (or septic) tenosynovitis can have a bacterial. it is thought that there is a predisposition to their development (Weilby. 8. These conditions commonly involve: 1. The tendons of the first dorsal compartment (de Quervain’s disease) (Fig. As with peripheral nerve compression. Dupuytren’s disease.. Triggering of the digits or thumb Constriction at the level of the metacarpal head results from the disproportionate size of the flexor tendon in relation to its overlying retinacular pulley (i. flexor carpi ulnaris tendon) or gout.3). Extensor pollicis longus is much less frequently involved. diabetes. Flexor carpi radialis (Fig. the retinacular sheaths can thicken considerably and the tendon will show signs of attrition (Keon-Cohen. 4. Repeated movement of a tendon through such a confined passage can result in swelling and bunching of the tendon fibres (Hueston et al.1). intense local pain and sometimes crepitus. 2. Constrictive conditions ‘Stenosing tendovaginitis’ and ‘reactive tenosynovitis’ are two of the terms used to describe constriction of tendons at the wrist and in the fingers (Wolfe. 8. The flexor tendons of the digits and thumb (triggering). tuberculosis (Kozin and Bishop. amyloidosis. 1970).g.g. Constrictive tenosynovitis is more likely to be related to intrinsic anatomic and degenerative changes rather than being an inflammatory condition.2). With time. 1994). 3. systemic/metabolic disorders (e. mycobacterial.

flexor pollicis longus (FPL) can undergo attrition rupture due to bony spicules on the scaphoid. The more common tendon disorders on the dorsum of the hand involve the 1st and 6th compartments. The FCU tendon can be the site for calcific deposits near the tendon’s junction with the pisiform.e. Thickened tendon Patient presentation The incidence of trigger finger peaks in the sixth decade of life. Non-diabetic patients with longstanding triggering may also present with a PIP joint flexion deformity which is sometimes mistaken for Dupuytren’s disease or joint dislocation. lock into the flexed position. 1970). i. Corticosteroid injection Primary triggering of the digits can often be treated successfully with corticosteroid injection into the tendon sheath. The patient may complain of tenderness over the A1 pulley. pain on active flexion and/or ‘catching’ or ‘clicking’ of the PIP joint as the finger moves from extension to flexion or from flexion to full extension.2. The thickened flexor sheath can generally be palpated.100 The Hand: Fundamentals of Therapy Triggering at AI pulleys over metacarpal heads FPL EIP ECU tendonitis EDM APL EPB Site of intersection syndrome ECRL ECRB FCR tendonitis Calcific tendonitis of FCU FCU tendonitis Figure 8. Conservative management 1.3. Multiple digit involvement is more common in insulin-dependent diabetics who sometimes present with a mild PIP joint flexion deformity of the middle finger. followed by the ring. AI pulley Figure 8. The thumb is most commonly affected. Common tendon disorders on the volar aspect of the hand include triggering of the thumb and/or digital flexor tendons and tendonitis of flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU). Figure 8. The digit may actually ‘lock’ into flexion and require passive correction to restore digital extension. In rheumatoid disease. the tendons of abductor pollicis longus (APL)/extensor pollicis brevis (EPB) and extensor carpi ulnaris (ECU) respectively. middle. The disproportionate size of the flexor tendon in relation to its overlying retinacular pulley can result in pain on active flexion and cause the finger to ‘trigger’ or. Less common entrapment disorders involve the tendons of extensor indicis proprius (EIP) and extensor digiti minimi (EDM). little and index fingers (Weilby. Several digits can be affected at once.1. in severe cases. Success of this treatment is greater in patients with involvement of only .

i. The outcomes of splinting have been compared with those of injection at follow-up after one year and results have been encouraging.6).. This exercise maintains the differential glide of the flexor tendons within the sheath and is repeated 20 times at each session (Fig.5). Splinting Patients who do not wish to undergo injection or surgical release can be managed with a hand-based splint which immobilizes the MCP joint(s) of the affected digit(s) in neutral extension. the patient fully flexes and extends the digits 20 times. 1992). 1989). The purpose of this exercise is to maintain the differential glide of the flexor tendons. At the completion of this set of exercises. Figure 8. . 8. On a 2-hourly basis. The percutaneous method is contraindicated in patients with rheumatoid disease. however is ‘stepped down’ to allow MCP flexion of uninvolved digits.e. Sixty-six per cent of splinted digits were symptom-free compared to 84 per cent in the case of injected digits (Patel and Bassini.5.4). however. ‘place and hold’ flexion exercises are performed in the full-fist position. percutaneous trigger finger release is an alternative procedure (Stothard and Kumar. 1994). Every 2 hours during the day. Surgery The pulley is generally divided through an open procedure. If there has been no improvement during this time. The patient is asked to wear the splint during waking hours for an initial period of 3 weeks. the patient actively flexes Figure 8. (1988) and its aim is to rest the proximal pulley system by altering the biomechanics of the flexor tendons (Fig. Conservative management of trigger finger(s) involves a hand-based splint that immobilizes the MCP joint(s) of the affected digit(s) in neutral extension. 1993) (Fig.Conditions of the wrist and finger tendons 101 one digit and where duration of symptoms is less than four months (Newport et al. 1990). diabetes or those with excessive subcutaneous tissue (Froimson. The splint prevents flexion at the MCP joint(s) of affected digit(s). 2. a further 3 weeks of treatment can be trialled. This manoeuvre maintains mobility of the MCP joints and avoids the ‘triggering’ that can occur with active digital flexion from the fully extended position. Early active movement is begun within a day of surgery and scar management is commenced upon removal of sutures. If symptoms persist. 8. the injection can be repeated on two more occasions without the risk of possible complications such as skin depigmentation. the fingers into a ‘hook fist’ and then actively extends the digits to full range.4. skin atrophy or tendon rupture (Marks and Gunther. 8. the fingers are passively placed into full flexion at all three digital joints and the patient is then asked to gently maintain this fully flexed position for several seconds. This treatment protocol was devised by Evans et al. If the patient has shown some improvement during the 3-week period. steroid injection or pulley release are indicated.

sensitivity in this region can be quite marked. The patient may complain of an ache in the thumb and this may radiate proximally into the forearm. Note the superficial branches of the radial nerve which are vulnerable to injury during decompression. Open release of the A1 pulley.7. de Quervain’s disease) involves the tendons of abductor pollicis longus (APL) and extensor pollicis brevis (EPB). there is tenderness over the radial styloid. the test is said to be positive. The fingers are then flexed over the thumb and the patient is asked to ulnar deviate the wrist. Pain is aggravated by movement of the thumb. 8. This is referred to as the ‘hitch-hiker’s’ test. Where this manoeuvre elicits intense pain. the following test is performed (Finkelstein. intersection syndrome where symptoms of pain and swelling of the APL and EPB muscle bellies occur 4–6 cm proximal to the Open release of the AI pulley Figure 8. Differential diagnosis Conditions that can present similarly to de Quervain’s disease include arthritis of the first (CMC) joint (which may coexist with this condition) and. This is the most radial of the six dorsal extensor compartments and houses the sheaths of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) at the radial styloid process.. de Quervain’s disease can present acutely from a local blunt injury to the styloid process. . Stenosing tendovaginitis of the tendons in the first dorsal compartment (i. 2.e.6.8). The patient is asked to flex the MCP and IP joints of the thumb across the palm. 1991). Patient presentation The patient generally presents with pain and swelling on the radial aspect of the wrist. rarely. more often.7). de Quervain’s disease de Quervain’s disease is stenosing tendovaginitis of the first dorsal compartment (Fig. There may be thickening of the retinacular roof. Occasionally. an associated ganglion and/or there may be radial nerve neuritis. On palpation. 8. This manoeuvre can be uncomfortable in the normal wrist so comparison with the non-involved side should always be made (Fig. lie in separate tunnels. APL (which often has several slips) and EPB can share a tunnel or. 1995). Resistance given to thumb extension at the level of the MCP joint can also be suggestive of EPB inflammation (Kirkpatrick and Lisser. If there is also involvement of the superficial branch of the radial nerve. Diagnostic manoeuvre To help establish the diagnosis of de Quervain’s disease. 1930).102 The Hand: Fundamentals of Therapy these anatomic anomalies may account for the poor response of some patients to conservative management (Minamikawa et al. Aetiology This condition can result from activities that require frequent thumb abduction in combination with ulnar deviation of the wrist. It has been suggested Branches of superficial radial nerve EPL 1st Dorsal compartment housing APL and EPB tendons Figure 8.

Figure 8. The tendons are decompressed from their musculotendinous junctions proximally. the patient can be fitted with a soft neoprene wrist/ thumb wrap that provides elastic support without hindering movement. Figure 8. The wrist is held in neutral or slight extension and the thumb is held in comfortable palmar abduction.8. Surgery Surgical treatment involves decompression of the first dorsal compartment through either a transverse or longitudinal incision (Fig. wrist rather than 1–2 cm as in the case of de Quervain’s disease. to about 1 cm distal to the retinaculum. Success rate with steroid injection. Conservative management In the first instance.9.. conservative management of de Quervain’s disease has a higher success rate in cases that are relatively acute.10. then flexing the fingers over the thumb and ulnar deviating the wrist.9). there should be cessation or modification of the precipitating activities. ranges from 50 to 80 per cent (Harvey et al. While this manoeuvre is uncomfortable in the normal wrist. A volar lip of retinaculum is maintained to minimize the risk of volar dislocation of the APL tendon. As in the case of triggering. A soft neoprene thumb/wrist wrap provides support while allowing movement when activity is resumed. Splinting involves resting the wrist and thumb for a period of 3 to 4 weeks.11). A positive Finkelstein test helps confirm the diagnosis for de Quervain’s disease. To expedite progress. splinting can be used in association with steroid injection into the synovial sheath of the first dorsal compartment. While a transverse incision leaves a more cosmetic scar. At the completion of the immobilization period. 8. 8.10). the subcutaneous fat is incised by using gentle blunt longitudinal dissection. . The IP joint of the thumb is left free to move. given once or twice. This test involves flexing the thumb across the palm. To avoid injury. 1990). exposure is compromised and the risk of injury to the superficial branch of the radial nerve is therefore greater. The compartment is explored for the presence of intervening septa which will require complete division. the thickened compartment sheath is longitudinally incised on its dorsal surface. it usually elicits intense pain in patients with de Quervain’s disease. This support is particularly helpful for patients who are returning to work (Fig. Under direct vision. The function of each tendon is tested for independent movement. The terminal joint of the thumb is left free to move (Fig. 8. Conservative management of de Quervains’s disease includes temporary immobilization in a thermoplastic splint that maintains the wrist in neutral or slight extension and the thumb in a functional degree of palmar abduction.Conditions of the wrist and finger tendons 103 Figure 8.

I. J. increased pain will help suggest the diagnosis (Fitton et al. E. (1990).. S. decompression of the sixth dorsal compartment is carried out. (1968). Green. 1994). 12. Most cases settle within 2 to 3 weeks. References Bishop. pp.. Harvey. A. Stenosing tendovaginitis at the radial styloid process. J. and Soin. M. In Rehabilitation . (1973). J. T. Harvey.. Injuries of the hand. J. A. 1009–14. (1988). W. De Quervain’s disease. This appears to render the tendon vulnerable to both primary tendovaginitis and to the secondary effects of carpal degeneration (Bishop et al. M. Kirkpatrick.. J.. 83–7. 1044–5. T. (1993).. In Green’s Operative Hand Surgery (D. Lesions of the flexor carpi radialis tendon and sheath causing pain at the wrist. Decompression of the 1st dorsal compartment 4. and Carmichael. Conservative management of the trigger finger: a new approach. Finkelstein. (1995). can be difficult to distinguish from other pathology in this area. K. and Horsley. B. Tenosynovitis and tennis elbow. W. 76A. 509. S. Bone Joint Surg.. non-steroidal antiinflammatory medication and corticosteroid injection. Bone Joint Surg. S. Gabel. 2.104 The Hand: Fundamentals of Therapy Where tendovaginitis is secondary to arthritic lesions. (1951). Treatment Conservative treatment includes ice (in the immediate postinjury phase). F. 15A. Med. P.). Patient presentation The patient is typically a middle-aged female who presents with pain over the scaphoid tubercle. A volar lip of retinaculum is maintained to minimize the risk of volar dislocation of the APL tendon. F. De Quervain’s disease: surgical or nonsurgical treatment. (1994). M.. Gentle active movement and light use of the hand is then begun. Aftercare The wound is covered with a soft bulky dressing that restricts movement of the thumb for the first few postoperative days. wrist splinting in extension.. When the patient is asked to actively flex and radially deviate the wrist against resistance.. W. G. In Surgery of the Hand.. A provocative manoeuvre that points to the diagnosis involves giving resistance to wrist extension and ulnar deviation. J. R. 50B. and Goldie. Treatment This condition usually responds to a combination of rest in a wrist splint. Extensor carpi ulnaris The tendon of extensor carpi ulnaris can become inflamed following a twisting injury of the wrist or repetitive hypersupination with wrist ulnar deviation.11. 96–9. J. Bone Joint Surg. Shea. which presents with pain and swelling on the ulnar side of the wrist. Patients who develop problems of marked hypersensitivity from irritation of the radial nerve are also treated with transcutaneous electrical nerve stimulation. Hand Surg. Bone Joint Surg. Part 1: Operative anatomy. Flexor carpi radialis The tendon of flexor carpi radialis lies in its own tight fibrous canal and is anchored rigidly to the wall of the trapezium. J. B. Lippincott. 496–9. (1944). This condition. Hand Ther. There may be some local swelling and an overlying ganglion. Bunnell. M. Churchill Livingstone.. Froimson. J. W. (1930). arthritis of the distal radioulnar joint or tears of the triangular fibrocartilage. J. W. Hunter. P. Flexor carpi radialis tendinitis. W. The sheath of the 1st dorsal compartment is incised longitudinally on its dorsal surface. Keon-Cohen. Fitton. J. 33B. Figure 8. 59. This results in increased pain which may be accompanied by crepitus within the swollen sheath. Hueston. Aust.g. F. e.. decompression of the tendon may be indicated to avoid attrition rupture. H. 1. Evans. and Burkhalter. Raised and/or sensitive scar is managed with Opsite Flexifix and silicone gel. and Lisser. W. 3. Trigger thumb. Soft tissue conditions: Trigger fingers and De Quervain’s disease. Where symptoms persist. Wilson. 1968). anti-inflammatory medication and corticosteroid injection. H.. ed. 359–63.

C. S. D. J. inject or operate. J. Bone Joint Surg. J.. 482–5. M. 39. W. J. J. Minamikawa. S. R. Pederson.. J. A. R. Williams & Wilkins. M. T. A... In Green’s Operative Hand Surgery (D. trigger thumb and De Quervain’s disease. Hand Surg... 14. D. A prospective study of the results of injection of steroids and immobilization in a splint. G. and Garcia. Hand Surg. 439–47. Coll. 714–21. 14A. and Seidman. R. 1007–15. Orthop. (1955). W. (1991). Patel. H. Complications of conservative and surgical treatment of De Quervain’s disease and trigger fingers.. E. JAMA. 540–4. Callahan. R. (1992). S. N. 116–7. and Bishop.. Marks. (1970).. S. E. M.. A.. 41. Sampson. Acta Orthop. Orthopaedics.) pp. 17A. C. L. (1994). Pathobiology of the human A1 pulley in trigger finger. Treatment of trigger finger by steroid injection. Hand Surg. F. J. complications and associated diagnoses. W. Hunter. L. In Flynn’s Hand Surgery (J. and Gunther. and Bassini. S. Acute calcium deposits in the hand. 21. Treatment of De Quervain’s tenosynovitis. 748–50. (1994). ed.. and Badalamente. P. C. Trigger finger. 10. eds) pp. 422–6. Y. Witt. H. Weilby. Surg. M. Med. J. Peimer. 73A. Mackin and A. S. (1999). Hand Surg. Lane. (1987). F. A. Acute calcific tendonitis in the hand. P. Tenosynovitis. (1990).. 480–7. P. S. 12A. S. 110–3. Rev. Hand Surg. Hand Surg. Cox. Sinton. Pess. De Quervain’s syndrome: surgical and anatomical studies of the fibro-osseous canal. A. J. 15A. R. (1901). (1986). and Kumar. 19A. 16A. A. L. Phalen. A. J. Hotchkiss and W. Atypical Mycobacterium infections of the upper extremity. Badalamente. Acute calcification in wrist and hand. 157. Wisch. Stenosing tenosynovitis: Trigger fingers.. J. and Gelberman. (1991). eds) pp. .. Sampson. 409. Green. 545–9. G. Hand Clin. M. A. and Sherwin.. J. 15. and Stuchin. (1994). Edinb. (1991). Churchill Livingstone.Conditions of the wrist and finger tendons of the Hand: Surgery and Therapy (J. 722–7. A safe percutaneous procedure for trigger finger release. Shaw. L. Scand. Newport. 2022–44. A. H. S. (1989). M. P. 419–27. Suisse Romande. Kozin. J. L. 219–22. Stothard. Secretan. Carroll. (1991). Hurst. Incidence in children and adults and the possibility of a predisposition in certain age groups... De Quervain’s release in working women: a report of failures. B.. M. Jupiter. R. 73–82. Oedema dur et hyperplasie traumatique du metacarpe dorsal.. 105 Further reading Arons. Rev. Wolfe. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. Trigger fingers and thumb: when to splint.

Patient presentation The patient with Dupuytren’s disease may present with a palmar or digital nodule. 1959). Aetiology The aetiology of this condition remains unknown. The significance of injury or occupation as predisposing factors in the development of Dupuytren’s disease remains controversial (Meagher. The pathologic tissue is comprised of immature collagen and fibroblasts. (Note the skip area where the skin is not tethered by the disease. These cords can displace neurovascular bundles and may cause soft tissue and joint contractures (Fig. 1990). The fascia undergoes pathological change which converts the normal bands and ligaments into diseased cords. a cord or both (Fig. There may be contracture of a single digit involving one or all three joints or there may be involvement of multiple digits and one or more web spaces. Current evidence points to a genetic predisposition. hyperextension deformity of the DIP joint and knuckle pads. rather than the condition itself. Earlier associations with epilepsy point to the drugs used in treatment. Unless associated with acute palmar fasciitis or carpal tunnel syndrome. interdigital web contracture.) . it is often more aggressive and difficult to treat.1. It is rare amongst Oriental and black races. The disease is seen most frequently in the populations of northern Europe. plantar nodules and Peyronie’s disease. Fat lying between the skin and the disease in this skip area will often contain the neurovascular bundle. flexion deformity at the MCP and/or PIP joints. The disease is associated with certain medical conditions. e.1).2). 9. 9.9 Dupuytren’s contracture Definition Dupuytren’s disease is a condition in which nodules and cords form in the palmar-digital fascia of the hand (Luck. Where the disease is present on the radial aspect of the hand. The stiff. 1990). It is also usually more aggressive in the younger patient. There may be extrapalmar ectopic deposits manifesting as knuckle pads. Dupuytren’s disease is usually painless. The presenting hand may be supple and mobile or thick with joints that are prone to stiffness. Features of the Dupuytren’s hand can include: palmar cords and nodules. diabetes and rheumatoid arthritis. Figure 9. The skin may or may not be involved.g. to account for the relationship (Hurst and Badalamente.

while in women it is 59 years. This little finger demonstrates a palmar nodule. Structures involved in contracture MCP joint Contracture of the metacarpophalangeal joint is caused primarily by involvement of the pretendinous band (Fig. (a) Normal components of the finger fascia.108 The Hand: Fundamentals of Therapy Figure 9. rendering it susceptible to injury during surgery (Umlas et al. (b) When diseased. Figure 9. Contracture can also result from diseased fascia of the intrinsic musculature.3. Although the disease appears later in women. Disease of the natatory ligament causes web space contracture which will limit finger span.3). Contracture of the MCP joint is caused primarily by involvement of the pretendinous band. natatory or spiral). The average age of onset in men is about 48 years. the spiral band. 1994). a palmar-digital cord and a marked PIP joint flexion deformity. (b) (a) Cleland’s ligament Grayson’s ligament Lateral digital sheet Spiral cord Natatory ligament Neuravascular bundle Pretendinous band Spiral band Superficial transverse ligament Central cord Lateral cord Intrinsic muscle Pretendinous cord Figure 9. arthritic or sweaty hand is prone to post-surgical complications.e. The overall incidence of this complication is approximately 5 per cent. the postoperative complication of chronic regional pain syndrome is double that of men. PIP joint The bands and ligaments which become diseased. lateral. There can be associated triggering of the finger or carpal tunnel syndrome.. The spiral cord is comprised of: the pretendinous band. the lateral digital sheet and Grayson’s ligament (Fig. lateral and central cords which result in flexion contracture of the PIP joint. Of the various cords that can develop in the digit (i. Surgical correction of this joint is therefore more difficult.4. it is contracture of the spiral cord that can significantly displace the neurovascular bundle. and is usually less severe. the normal components of the digital fascia are converted into the spiral. .2. central. 9.4). Note the skin excoriation. These conditions are more likely in diabetic patients. are several in number. 9. resulting in contracture of the PIP joint.

the disease can extend beyond the field of surgical clearance. 3. .g. Cure of the disease by complete fasciectomy. Return of maximum flexion range can take some months. In the younger patient with a strong Dupuytren’s diathesis and progressive contracture. A combined thumb and thumb web contracture is approached by an incision both along the thumb ray and the thumb web. Skin excoriation. Results Approximately 80 per cent of patients can expect to gain a near-normal range of extension following surgery. Contractures of the PIP joint of 30 degrees or less are generally not treated by surgery (McFarlane and Botz. Such cases of mild deformity with slow progression are monitored on a 6 to 12 monthly basis (Fig. Both incisions are converted to a single or double Z-plasty at closure (Fig. but some may have difficulty regaining full flexion after surgery. Poor general health. 1990).g. therefore. more radical surgery is advised.6. Limited surgery is advisable for the elderly patient. Types of incision. Transverse disease in the palm can be approached by a midpalmar incision. 2.6).Dupuytren’s contracture 109 with coexisting problems. Surgery is indicated where the patient presents with a functional disability or where there has been rapid progression of the disease. A patient who is unable to comply with the postoperative therapy regimen. ischaemia and infection. Long-term results show a recurrence rate ranging from 25 to 80 per cent. maceration or infection. particularly in the older patient Types of incision Palmar-digital contractures are approached through a longitudinal incision which is converted to a Z-plasty at closure.5). Contraindications for surgery Figure 9. Studies suggest that this rate is influenced not so much by the surgical technique as by the disease process itself. 9. particularly in the web space. Longitudinal incision Mid-plamar incision Thumb ray incision Figure 9. Indications for surgery Surgery is indicated if the patient presents with a functional disability or where there has been rapid progression of the disease. 4. it is prudent to inform the patient of their possible occurrence. These include the following: 1.5. 9. Arthritis in the hand which is likely to be exacerbated by surgery. Most patients with Dupuytren’s contracture can make a normal fist before surgery. osteoarthritis or diabetes. Because of the potential for a number of postoperative complications. Patients who request surgical treatment for cosmetic reasons should be warned of the possible risk of losing some hand function. is not possible. Biologically. e. e. Full-thickness skin grafting alone has been shown by Hueston (1984a) to decrease recurrence rate.

If this is unsuccessful. Microscopic repair of the digital nerve and artery may be necessary if intraoperative damage has occurred. Recurrence of the deformity. Capsulotomy of this joint may need to be performed in association with division of the extensor tendon to allow DIP joint flexion (Belusa et al. 4. only the diseased fascia is removed.110 The Hand: Fundamentals of Therapy Types of operation 1. 1984b). (iii) As a first-stage procedure for advanced disease where there may be skin excoriation. Regional (or limited) fasciectomy In this procedure. (ii) The elderly patient. where recurrence rate is higher. The skin is also removed if it is rendered non-viable through the dissection process. Release of DIP joint extension contracture. Prophylactic dermofasciectomy is indicated for recurrent and advanced disease. . It carries a high complication rate with questionable reduction of recurrence.7). 3. percutaneously) or by open technique. it is resected and a full-thickness skin graft is used to cover the defect. Associated procedures 1. palmar plate and sometimes the accessory collateral ligament is required. Indications for this procedure include: (i) An MCP joint contracture that is due to a discrete palmar pretendinous cord with mobile overlying skin. Extensive (or radical) fasciectomy This procedure involves resection of all palmar fascia but only digital fascia that is involved in the disease process.e. This is the most commonly performed operation and in experienced hands gives the best results (Fig. This results from involvement of the oblique retinacular ligament which requires surgical division. It may be performed either closed (i. After removal of the involved fascia. A severe longstanding PIP joint contracture is often associated with hyperextension of the DIP joint. 1997). A longstanding contracture may have caused attenuation of the extensor apparatus. is more likely. 9. particularly in the younger patient. 2. Gentle manipulation is attempted. Theoretically. preventing recurrence deep to the grafted ‘firebreak’ (Hueston. 3. It is commonly performed in the palm where results are more satisfactory than those gained in the finger. formal surgical division of the flexor tendon sheath. the PIP joint may remain contracted. 2. Figure 9. Regional (or limited) fasciectomy is the most commonly performed operation and gives the best results in experienced hands.7. however. Fasciotomy is a less invasive procedure than fasciectomy and recovery is therefore faster. Dermofasciectomy Where skin is also involved in the disease process. Fasciotomy This procedure involves simple division of a Dupuytren’s cord. The open technique involves dissection of the neurovascular bundle. Release of PIP joint flexion contracture. skin grafting interrupts the contracting force..

Skin necrosis from inadequate circulation to skin flaps. Palmar fasciitis. Complications of surgery and healing A combination of the following factors predisposes to wound and other hand complications (Prosser and Conolly. e. Oedema. Extensive dissection involving the blood supply to the skin and deeper structures. Because the healing process involves a contraction. 5. 1964) technique Transverse wounds in the palm and digits will heal by spontaneous wound contraction over a period of 3 to 5 weeks depending on the size of the wound. Open wound (McCash. 2. especially at the PIP joint level. 4. 12. 3. The surgical raising of extensive thin flaps. Infection. 2. require frequent dressing change. Principles of postoperative management 1. This method of wound management does. Hypertrophic/contracting scar. Longitudinal wounds are best closed by Z-plasty over the midportion of the pulps and that part of the palm where the local skin is most mobile. 4. pain is minimal and active movement is begun early. Excision of scar tissue involving the flexor tendon sheath and IP joints. As the skin is not sutured. Restoration of flexion range and hand function. 1. The same applies to the Bruner zigzag incision. . 10. If the contracture is associated with severe involvement of the digital nerves and arteries. the wounds can be directly sutured. Division of the digital nerve. 3. 5. Types of skin closure 1. however. Direct suture Where incisions are made along neutral lines. 4. Scar management. Joint adhesions and stiffness. elective amputation at the PIP or MCP joint level may be a better option. 5. 11. Early diagnosis and prevention of wound complications. 7. thrombosis or laceration during surgery. Recurrence of the deformity as the disease inevitably extends beyond the field of surgical clearance. rather than a contracture. 9. Areas with optimal blood supply are chosen.g. 2. multiple Z-plasties or four-times Z-plasty. i. 4. If the contracture is irreversible. Treatment of oedema. Skin graft A full-thickness skin graft is preferable to a splitthickness skin graft because it has considerably less tendency to contract. The incidence of this is approximately 5 per cent and it is seen twice as often in women as in men. The presence of diabetes. Local flaps Local flaps include single Z-plasty. 2. the eventual scar line is negligible. 6. 3. Slow healing of the operative wound due to poor circulation following months or years of fibrosis. 3. Ischaemia of the digit from digital artery spasm. Tendon adhesions. 1996): Older age of patient. The Z-plasty interrupts the line of potential skin contracture and gains skin length after release of the contracture. where there is no skin tension in any position in the palm or digit. Such a wound drains freely and haematoma is therefore avoided and infection is rare. 6. Haematoma: this manifests postoperatively as throbbing pain and is not relieved by analgesics.Dupuytren’s contracture 111 4. Maintenance of surgical correction. removal of sutures from any area of skin with poor circulation. the patient may opt for joint fusion in a functional position. Involvement of the skin in the disease process. Chronic regional pain syndrome (formerly referred to as reflex sympathetic dystrophy).e. Complications include: 1. 13. 8.

Commencement of early active exercise in the absence of grafting. The therapist should remain alert to any signs that may herald the onset of chronic regional pain syndrome. 1995). The patient should be fitted with the appropriate size to avoid compromising circulation. Coban wrap or Tubigrip support for palmar or dorsal hand swelling. The glove should fit snugly but should not cause throbbing or numbness. the wound can be soaked once or twice a day for 5 min in a solution of warm water (1200 ml) to which 20 g of salt has been added. Following this procedure. rather than the whole hand. Ice therapy. Compression wrap. e. Autonomic signs such as excessive sweating or mottling of the skin. This is prepared by boiling the water.8). 9. Oedema can be managed by: 1.112 The Hand: Fundamentals of Therapy Monitoring of the hand The appearance and condition of the hand is monitored closely during the first few weeks after surgery as changes in hand circulation and oedema can be quite marked from one therapy session to the next. If flexion range is Figure 9. The replacement dressing should be minimal so that exercises can be performed in an unimpeded manner. 3. Refer to the chapter on ‘Chronic regional pain syndrome’ for management. It should be pointed out to the patient that active flexion exercises are a little more ‘challenging’ to perform with the glove in place due to the gentle extension force exerted by the elasticity in the material. the wound is redressed with a non-adherent dressing. 3. 2. If skin grafting has been carried out. It is distinguished from this condition by the fact that it is usually confined to the area of surgery. tension should be negligible and application is in a distal to proximal direction. Dressings should be renewed at each treatment session so that the wound can be assessed for any signs of infection or haematoma.8. adding the salt and allowing the solution to cool until tepid. gentle application of a crepe bandage. Persisting oedema can result in fibrosis of the joints and soft tissues which leads inevitably to stiffness. the patient is seen at least 2 to 3 times a week for the first fortnight. postoperative hand oedema should be anticipated. and tends to settle within a few days. Oedema that worsens rather than improves during the course of the day. Occasionally following surgery. Ideally. Patients who have undergone regional fasciectomy will have had primary closure of their wounds. the patient will present with a ‘flare’ reaction which can have a similar appearance to CRPS. Adaptic). layer of gauze and a layer or two of bandage or Tubigrip stockinette. e. Pain that progressively worsens rather than eases. These signs include: 1. . Lack of progress in regaining flexibility (in the absence of arthritic changes).g. Wound care The hand therapy programme is commenced 2 to 3 days following surgery. Where hand oedema persists beyond the wound healing stage.g. When the open-palm technique is used. 4. Silicone scar gel can be used beneath the compression glove. The patient is encouraged to perform gentle active exercises while the wound is soaking (Fietti and Mackin. 2. a lycra compression glove is applied. Elevation (for at least the 1st postoperative week). 4. When applying Coban wrap to the digits. If hand swelling persists beyond wound healing. Treatment of oedema Because surgery for Dupuytren’s disease is often quite extensive. a lycra compression glove is applied (Fig. exercise is deferred for 7 to 10 days during which time the hand usually remains in its postoperative plaster.

The gel is washed on a daily basis and is left off the skin for at least 4 h each day to avoid skin maceration. Figure 9. the splint is left off for increasing periods throughout the day so that flexion range can be regained. . Maintenance of surgical correction The postoperative splint is most important in maintaining the extension range achieved at surgery. Regaining movement All joints proximal to the hand should be exercised regularly throughout the day to prevent stiffness. adhesive silicone gel (Cica-Care) is applied to the scar and used in conjunction with the extension splint. 1992). This serves to desensitize as well as soften the scar. After this time. A dorsal hand-based outrigger can be used to maintain correction following a single digit PIP joint release. Where there has been correction of a single digit contracture or where correction has been localized to the PIP joint. If there are areas of diminished sensation. it is sometimes necessary to place the wrist into slight flexion to avoid undue tension on the palmar tissues. Many patients are able to demonstrate improved flexion range while wearing the glove because the support it provides can reduce discomfort during exercise. This splint has the advantage of allowing active PIP joint flexion against the rubber band traction. a dorsal hand-based outrigger splint can be fitted (Rives et al. 9. Scar management When the wound has healed. To assist scar resolution.9). dry and oil-free skin. Wearing of the splint at night is continued for 6 months after surgery (Fig. To accommodate a comfortable finger extension range in the immediate postoperative phase. being removed only for dressing changes and 2-hourly exercise sessions. the wrist may need to be placed in slight flexion. The linear scar resulting from the open-palm technique is usually minimal. oil massage is commenced. This dynamic splint has the advantage of allowing active motion while the splint is being worn. This splint is usually a static one and can be applied either on the volar or dorsal aspect of the hand and forearm. Surgical correction is maintained with a static volar extension splint. 9. the patient is given advice regarding protection from injury. The splint should extend from just distal to the fingertips to two thirds along the forearm and extend mid-laterally on the ulnar and radial aspects of the forearm (Fig. Although the gel is quite costly. To avoid placing undue tension on the palmar tissues following surgery. The splint is worn continuously for the first 3 to 4 weeks. The gel is used only on clean. The plaster applied in theatre is replaced with a thermoplastic splint on the 3rd day.10). Figure 9. It can be held in place with a compression glove or a layer of Tubigrip. When present.Dupuytren’s contracture 113 significantly restricted. removal of the glove prior to exercise may be advisable. usually between 10 to 14 days. Grafted areas are massaged very lightly at first to avoid blistering of the skin.10.. allergy usually manifests as small red dots. one piece is usually sufficient for the duration of scar treatment which is generally 4 to 6 weeks. requiring little or no therapy intervention.9. On the first day. the skin is checked every few hours for irritation or signs of allergy which are rare.

277–81. Surg. M. J. The effectiveness of these soaks cannot be overemphasized.11). Dupuytren’s contracture: A new concept of the pathogenesis correlated with surgical management. McGrouther and M. L. N. PIP and DIP joints simultaneously until maximum passive flexion is achieved without undue discomfort. T. 41A. Movements should not cause pain and they should be performed with the hand is slight elevation to assist resolution of oedema. When reasonable passive flexion range has been achieved. J. ‘Firebreak grafts’ in Dupuytren’s contracture. (1984b). . the fingers are gently bandaged into flexion for 15-min periods several times a day. 44. Bone Joint Surg. H. J. D. eds) pp. this manoeuvre should be combined with the warm water soaks. D.11. and Mackin. 2. Plast. Hunter. Inst.. Exercise sessions should therefore be repeated at least 2-hourly during the early postoperative phase. To help overcome interphalangeal joint stiffness. V. Joint Dis.. Mosby. warm water soaks are commenced. 253–60. V. and Badalamente. Flint. Each digit is exercised individually with the therapist passively flexing the digit at the MCP. (1959). Others must persevere with their home programmes for several months before regaining a flexion range that is consistent with good function. Fietti Jr. eds) pp. in which case movement of the grafted area is delayed for 7 to 10 days. Where interphalangeal joints are quite stiff. J. The Hand and Upper Limb Series (R. Z. C. E.. (1984a). Individual finger exercises are followed by 10 global flexion (or fistmaking) exercises. 10 active stabilized IP joint flexion exercises are practised. (1997). Aust. G. T.. M. (1995). In Rehabilitation of the Hand: Surgery and Therapy (J. The advantages include: 1. Associated diseases.114 The Hand: Fundamentals of Therapy This applies particularly to the shoulder joint of the older patient. Mikrochir. Chir. L. Hueston. In Dupuytren’s Disease. the fingers can be bandaged into flexion several times a day for a period of 10 to 15 minutes. M. D.. Increased movement. The effect of this stretching manoeuvre is augmented if the hand is immersed in warm water. D. Debridement of the wound. 224. Hurst. For extra effectiveness. J. Mackin and A. J. Dermofasciectomy for Dupuytren’s disease. 9. A. Bull Hosp. Callahan. McFarlane. 995–1006. Orthop. Because patients with Dupuytren’s disease tend to be in the older age group and because surgery is frequently quite extensive. Luck. As soon as allowed (usually after the 1st postoperative week). 54. This position is held for a short time (30–60 s) after which the patient actively extends the digit. Squeezing a soft sponge improves mobility and helps to reduce hand swelling. This is particularly the case in colder weather. Soaking the hand in warm soapy water has a soothing effect and helps facilitate movement. (1990). Churchill Livingstone. the propensity toward stiffness is great. Buck-Gramcko. Handchir. Hueston. 29. 158–63. and Partecke. References Belusa. 3. 635–64. Open-palm technique in Dupuytren’s disease. A mild cleansing agent can be added to the water. E. J. Biology and Treatment. Results of interphalangeal joint arthrolysis in patients with Dupuytren’s disease.. Some patients regain flexion range quite quickly. An IP joint flexion strap will help gain the final degrees of flexion range (Fig. Reduction of pain. Gentle passive and active wrist and finger movements are commenced on the 2nd postoperative day unless there has been skin grafting. The patient should be informed that grip strength can take many months to return and that activity levels should be gradually increased commensurate with improvement. B. Figure 9.

97. Scand. 362–6. A. Plast. Hueston. S. (1995). D. T. E & S Livingstone. E. (1996). and Morrison. 21B. 51–63. Surg. Sterne. McGrouther and M.. P. Lattuga. The open palm technique. J... A. 271. Hand Clin. In Dupuytren’s Disease. H. (1964). 560–6. 9. 21A. Lanzetta. Gelberman. G. G. K. Hand Ther. D. J. Dupuytren’s contracture. H. 193–7.. Smith. J. J. M. M. eds) pp. P. Plast. C. Dupuytren’s disease occurring after a surgical injury of the hand. and Logan. C. E. and Botz. M.. Dupuytren’s disease: relation to work and injury. R. 490–5. Prosser. 267–71. L. Biology and Treatment. In Green’s Operative Hand Surgery (D. The transverse elements of the palmar aponeurosis in Dupuytren’s contracture. Churchill Livingstone. A comparison of methods of treatment of PIP contractures in Dupuytren’s disease.. (1997). Fitzgerald. Starkweather. Hand Surg. McGrouther. N. J. Dupuytren’s contracture. and Turner... Hurst. J. Mosby. 7. The Hand and Upper Limb Series. McFarlane. Chir. J.. Br. An investigation into the role of inflammatory cells in Dupuytren’s disease. (1990). Open palm technique for Dupuytren’s disease. The results of treatment. Skoog. (1994).. Hotchkiss and W. McFarlane. (1991). S. (1996). R. C. and Fleegler. (1963). Manual work and industrial injury: A personal commentary.. J. 17. eds) pp. Weinzweig. J. M. R. (1996). Skin replacement in Dupuytren’s disease. A. Long-term results after segmental aponeurectomy for Dupuytren’s disease. F. A. Burke. eds) pp. 21B. B. N. W.. (1992). (1991). J. R. S.. Flint. Super. Ann. E. and Conolly.. H. B. et al. Complications following surgical treatment for Dupuytren’s contracture. L. P. Churchill Livingstone. 21B. In Dupuytren’s Disease. Hand Surg. D.. In Rehabilitation of the Hand: Surgery and Therapy (J. Predictors of neurovascular displacement in hands with Dupuytren’s contracture. Results of a prospective trial of operative correction and dynamic extension splinting. W. Mackin and A. 11. B. J. and Smith. Green. A five-year follow-up. 387–412. J. D. Dupuytren’s disease. N. eds) pp. 19B. 1..Dupuytren’s contracture McCash. Surg. Hand Surg. Umlas. J. Moermans. M. E. R. Hand Surg. Main Memb. M. Breed. Schneider. R. Churchill Livingstone. A. Andrew. 17A. and Gelberman. 115 Further reading Andrew. (1967). 5 (R. Bischoff.. 16B. A. 481–3. J. J. . (1999). 563–91. (1996). Meagher. H. C. J. J. The open palm technique in Dupuytren’s contracture. J. (1991).. Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease: Combined fasciectomy with capsuloligamentous release versus fasciectomy alone.. Hand Surg. (1990). P. Ash. 9B. Pederson. and Varian. M. J. Hand Surg. S. J. 261– 4. Rives. E. Plast. 344–8. Callahan. D. Cornil. R. Dupuytren’s contracture: A comparative study of fasciectomy and dermofasciectomy in one hundred patients. J. 981–94. 246–51. Hand Surg. Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease. McFarlane. R. Surg. Flint. Tonkin. McGrouther and M. A. W.. A. Vol. Hall. (1992). 5 (R. Hunter. D. The Hand and Upper Limb Series. T.. Hand Surg. (1996). Hand Surg. and MacDermid. Biology and Treatment. 156–62.. 664–6. 797–800. K. M. and Carney. M. Hand Surg. R... McFarlane. McFarlane. 723. 16A. K. C. D.. Foucher. (1984). J. Collagenase in the treatment of Dupuytren’s disease: An in vitro study.. J. Culver. 22. (1996). Reconstr.. J. W. Vol. 1153–9. M.. and Lenoble. P. 775. C. M. G. M.

Oblique views are particularly important for the assessment of intraarticular fractures. During flexion.10 Fractures of the hand Jacki Shannon-Johnstone Fractures to the hand are common and most can be treated conservatively by simple closed reduction. Rotational deformity can be assessed by noting the position of the fingernails when the digits are extended. According to site. accounting for nearly 50 per cent of all hand fractures. The remaining 20 per cent occur in the proximal and middle phalanges (Meyer and Wilson. ‘scissor’. 2. rotational. Three views are required: anteroposterior (AP).e. spiral or comminuted.e. i. Metacarpal fractures account for approximately 30 per cent of fractures. Local anaesthetic should be administered prior to the test to eliminate pain. angular or shortening. thus ensuring a more favourable outcome. Crushing injuries produce comminuted fractures which nearly always shorten and may rotate or angulate. According to fracture geometry. Radiological examination Good quality X-rays are essential for accurate diagnosis. According to fracture deformity. it should be carried out after fracture evaluation. 1989). Mechanism of injury The mechanism of injury will determine the type of fracture. These tend to produce angulatory deformities which can be seen in both lateral and frontal radiographic views. 1995). oblique and lateral. 3.e. base. 1993). protective splinting and early mobilization (Pun et al. i. Orientation of the fingers should be Because stress testing for ligament damage has the potential to displace a fracture. Closed or open.e. Non-operative treatment is preferred wherever possible to avoid further trauma to the soft tissues. Stable or unstable. 4. oblique. i. i. A direct blow will usually result in a transverse fracture. transverse.1): 1. They generally lie in the same plane as one another. Soft tissue injury Assessment 1. compared with the opposite hand. neck or head. The degree of soft tissue injury associated with the fracture has a direct correlation to the final range of motion (Duncan et al. . fingers are checked for a tendency to cross over one another.. 2. 10. A spiral or oblique fracture results from a twisting injury. shaft. 3. The most commonly fractured bone in the hand is the distal phalanx. 5. Oblique fractures result in rotatory deformities but may also angulate or shorten. Classification of fractures Fractures of the metacarpals and phalanges can be classified in the following way (Fig..

10.e. (c) Figure 10. (a) Stable. Intra-articular or extra-articular. in a POSI splint (Fig. 3. 2. . 10. tendon or neurovascular injuries. Collateral ligament Palmar plate (a) (b) Figure 10. Appropriate analgesia will be required and an X-ray should be taken prior to and post reduction to ensure bony alignment has been achieved. The hand is placed in the ‘position of safe immobilization’ following fracture reduction. Both these contractures are commonly associated with fractures of the hand (Fig. Stable fractures A fracture is considered stable if the bone fragments do not displace when stress is applied.118 The Hand: Fundamentals of Therapy (a) Figure 10. Maximum MCP joint flexion (usually 80 to 90 degrees). Wrist extension of 30 to 40 degrees. The position of safe immobilization maintains the collateral ligaments of all finger joints at optimal length thereby avoiding the tendency toward extension contracture of the MCP joints and flexion contracture of the PIP joints. 7. Gentle active range of movement can usually be commenced several days following injury. 6.2). Stable fractures may require temporary splinting to support the soft tissue and to relieve pain.3). The collateral ligaments of the MCP joints are (a) relaxed and short when the joints are extended and (b) stretched when the joints are flexed. i. Displaced metacarpal and phalangeal fractures can often undergo closed reduction.3. This position is also referred to as the ‘intrinsic plus’ or ‘clam-digger’ position and is as follows: 1. (c) unstable. (b) potentially unstable. Classification of fractures.2. (b) Position of safe immobilization Following reduction the hand is rested in the position of safe immobilization.1. Maximum interphalangeal joint extension (ideally 0 degrees). By the presence or absence of associated ligament.

K-wires often require support splinting or supplementary techniques as they do not provide rigid internal fixation. Some surgeons prefer to bury the pin while others prefer to let it protrude through the skin. Open reduction and internal fixation Approximately 10 per cent of phalangeal and metacarpal fractures require open reduction and internal fixation (Melone. Intra-articular fractures. Multiple fractures. Screws and plates provide more stability. 2. Pathological fractures (e. 2. Fixation methods. The complication rate associated with the use of K-wires in the hand and wrist is 18 per cent (Botte et al. (a) Crossed Kirschner wires are most suited for transverse fractures. They are unsuitable for comminuted or open fractures or in association with significant soft tissue injury. 10. In long oblique fractures the wire is placed perpendicular to the bone. Crossed K-wires are most suited for transverse fractures. Indications for open reduction and internal fixation are: 1.. (c) lag (or compression) screws can provide rigid fixation. 2.Fractures of the hand 119 Unstable fractures In an unstable fracture. The reduction is more accurate. Internal fixation is needed to restore and maintain normal bony anatomy. improved materials.g. e. Rotational malalignment. Open fractures. 7. rotation osteotomy for malunion. . Kirschner wires Kirschner wires (K-wires) offer the simplest technique for fracture fixation and because they can be inserted percutaneously. 3. usually seen in spiral and oblique fractures. 3. (b) composite wiring converts distraction forces into compression forces. 5. e.g. Wiring Because K-wires on their own do not provide rigid fixation or rotational stability. bony alignment is easily lost. They can be used for nearly all types of fracture. 1986). Unstable fracture where closed reduction cannot be achieved or maintained. Open reduction has gained greater acceptance over the past two decades due to increased understanding of the biomechanical principles of internal fixation. Fixation methods (Fig. 6. In spiral fractures they are placed in parallel. The advantages of open reduction and internal fixation of hand fractures are: 1. they can be placed with minimal soft tissue dissection.g.4. enchondroma). Movement can be commenced within a day or two of surgery. particularly where there is bone loss. 4. 8. increasing specialization in surgery of the hand and antibiotic availability to minimize the risk of infection. Malunion or non-union. 1992). Fractures associated with soft tissue damage requiring surgery. tendon and/or nerve damage. Reconstruction. (d) plating provides longitudinal stability that can resist bending as well as torsional forces.4) 1. While a simple and relatively cheap technique. they are often Figure 10. 9.

The articular fragments are reduced and the joint surfaces realigned by traction on their ligamentous and volar plate attachments. or movement of the fractured parts.g. rotation of a spiral fracture or angulation of a transverse fracture. Compression screws may be inserted through the plate’s holes if they are at suitable angles or they may be inserted away from the plate. They are also appropriate for unstable transverse fractures in a single digit.120 The Hand: Fundamentals of Therapy supplemented by wiring (composite wiring). Maximum compression is achieved with the screw at right angles to the fracture plane. Stiffness at this joint can be compensated for by the mobility of the basal thumb joint. 1992). tendon and nerve. These plates are low profile. pilon fractures.e. i. poor blood supply. interspersed fragments of tissue such as muscle. Plates Plating provides longitudinal stability that can resist bending as well as torsional forces. Compression of the fracture surfaces gives rigid fixation. Micro-plates from maxillofacial sets (Luhr Microfixation system) are now being utilized. the CMC joint. Intramedullary fixation Open reduction and intramedullary fixation can be achieved in transverse metacarpal shaft fractures using a Steinmann pin. These include comminuted open fractures which are often associated with bone loss and/or damage to soft tissues. A single lag screw is ideal for a small fracture fragment such as a unicondylar fracture of the head of the proximal phalanx. Plating is particularly suitable for multiple fractures. 5. It is useful for transverse shaft fractures.. Because this form of fixation does not interfere with mobility of adjacent joints.e. The two types of dynamic traction include the arcuate splint and the low profile lateral hinge traction splint (Dennys et al. Maintenance of traction throughout the healing process prevents collapse of the fracture fragments. External fixators can function either statically or dynamically. Lag (or compression) screw The lag or compression screw allows two fragments to be compressed together. Malunion. This process is termed ligamentotaxis. Delayed union or non-union caused by infection. This technique involves the use of three blunt and pre-bent flexible K-wires that ensure rotational control through 3-point fixation. This form of fixation is best suited to long oblique and spiral shaft fractures when the fracture length is at least twice the diameter of the bone. This technique is not suitable for long oblique or spiral metacarpal fractures. The interosseous tension band wire is passed as a figure of eight. This combined technique allows early active movement. the distal distraction force prevents contracture of the joint ligaments and other periarticular structures. i. Joint motion enhances cartilage regeneration and healing (see ‘Joint injuries of the fingers and thumb’). External fixation External fixation is reserved for severe fractures where restoration of the skeletal anatomy is not possible. A closed technique of intramedullary fixation is now available. Furthermore. (i) Static fixator A static fixator can be used across the MCP joint of the thumb for a comminuted intra-articular fracture. (ii) Dynamic fixator Dynamic traction combines the old method of traction with motion and can be used for unstable intra-articular PIP joint fractures. This technique has been described by Foucher (1995) in the management of displaced fractures of the fifth metacarpal neck and is known as ‘bouquet osteosynthesis’. thus allowing the periosteum to be closed with less tendency toward adhesion formation. . 3. it is particularly suited to replantation and fusion. Early active movement can be commenced with this form of fixation. e. especially those associated with soft tissue injury or for bone loss requiring grafting (Simonetta. 2. 4. Interosseous wiring requires minimal exposure and is less prominent than plates or screws. The distal distraction produces several effects. with the crossover lying external to the two fracture fragments. Composite wiring converts distraction forces into compression forces at the fracture site and is particularly suitable for unstable transverse or short oblique phalangeal fractures. 1970). Complications associated with fractures 1. 6.

with permission. D. (c) Last phase Phases of bone healing (Fig.6. (a) 3–5 weeks. (Reproduced from Meyer. Fracture consolidation varies within each segment of the hand and is slowest where the ratio of cortical to cancellous bone is highest. 4. (c) 10–14 weeks. Fibrin in the haematoma provides a framework for Figure 10. 5. N. Occasionally. In Rehabilitation of the Hand: Surgery and Therapy (J. i. Joint stiffness and contracture. and Wilson. eds) p. F. This results in vasodilation. i. E. bone healing occurs in three overlapping phases: 1. there is no motion at the fracture site when stressed and no pain with active movement . a fracture may be considered clinically healed.5. plasma exudation and migration of inflammatory cells to the fracture site. Management of nonarticular fractures of the hand. (b) 5–7 weeks. By the end of this phase.e. extension contracture of the MCP joints after metacarpal fractures or flexion contracture of the PIP joint following phalangeal fracture.5) Following a fracture. R. Mosby. 354. 10. The centre of the inflammatory reaction is made up of mostly cartilage. L. which usually lasts 4 to 6 weeks. 1950. The immature bone being formed at the periphery of this reaction is called hard callus. Reparative phase The fracture haematoma begins to organize. 2. Hunter. This soft callus is gradually replaced by bone. 1995. with permission). called soft callus.) migration of fibroblasts and undifferentiated mesenchymal cells.e. An inflammatory response is triggered by mediators released from dead and injured cells. 10. Mackin and A. Adherence of the closely allied flexor/extensor tendons resulting from postinjury oedema and/ or surgery.6(a)). Inflammatory phase This phase occurs in the 3 to 4 days following a fracture. Healing timetable for bone.Fractures of the hand 121 (a) First phase Thick cortex with almost no cancellous bone (b) Reparative phase (a) (b) (c) Figure 10. Callahan. (From Moberg. J. development of chronic regional pain syndrome. M. The gap in the bone is bridged with a blood clot which coagulates to form a haematoma. The cells increase in number and differentiate into what is known as fracture callus. 3. Osteoclasts resorb dead bone and fibroblasts start producing a new matrix (Fig. Diagrammatic representation of the three phases of fracture healing. There is ingrowth of capillary buds.

1935) (Fig. Figure 10. Metacarpal spiral fractures can result in rotational malalignment causing ‘scissoring’ of the digits during flexion. wrist in 30 to 40 degrees of extension. This problem is best managed with open reduction (Fig. Mild angulation in the ring and little fingers is considered acceptable (20 and 30 degrees. Much of this phase occurs in the first few months after injury. an imbalance between the extrinsic and intrinsic muscles can result. Primary bone healing When the fractured bone ends are brought into direct contact with one another.e. MCP joints in maximum flexion and IP joints in maximum extension. Osteoblasts are followed by new capillaries. however. respectively) because of compensatory mobility of the CMC joints in these two digits. Most shaft fractures can be successfully managed closed. Conservative treatment and therapy Splint position and oedema control Interosseous muscle Figure 10. Lamellar bone forms directly across the fracture site. In a transverse metacarpal fracture. Osteoclasts bridge the fracture line followed by osteoblasts. A half-plaster applied . (ii) Oblique and spiral Oblique metacarpal fractures have a tendency to shorten.6(b)). the interosseous muscles are responsible for dorsal angulation at the fracture site.8. i. Metacarpal fractures 1.122 The Hand: Fundamentals of Therapy of nearby joints. Angulation of the less mobile index and middle fingers.e. the interosseous muscles are responsible for dorsal angulation at the fracture site. primary bone healing occurs in two phases: gap healing and haversian remodelling. After fracture reduction. 10. 10. This forms new haversian systems called primary osteons. Remodelling phase During this phase lamellar bone replaces woven bone and callus is resorbed. however. Spiral fractures can result in rotational malalignment. Shaft fractures (i) Transverse (Fig. 10. Clinical healing occurs in about a quarter of the time it takes for complete bony healing to occur (Smith and Rider. 1983). At this stage there is usually little radiographic evidence of fracture healing. with open reduction and internal fixation. Where this exceeds 3–5 mm. this phase can continue for several years (Fig.7. i.7) In a transverse fracture. the hand is maintained for 3 to 4 weeks in the position of safe immobilization. is an indication for reduction and percutaneous pinning.8). Even a minor rotational deformity can be quite disabling as it will result in ‘scissoring’ of the digits during finger flexion (Opgrande and Westphal. Where angulation results in shortening of the metacarpal. a pseudo-claw.6(c)). which form new bone. 3. 10. i.e. compensatory hyperextension of the MCP joint will be present.

Heavy use of the hand is avoided until 12 weeks post fracture.9). Oedema Postoperative oedema is often marked. The patient is taught to initiate fist-making at the MCP joints otherwise the natural tendency.11). Intrinsic extension of the IP joints should follow each flexion exercise and the patient should aim to reach the level of the .e. i. Therapy following open reduction and internal fixation (ORIF) Therapy following ORIF is much the same as for conservative management (Fig. Coban wrap (50 mm width) or tubular support stocking (of appropriate tension) can be applied to the hand prior to moulding to assist with oedema resolution. The hand is placed in the ‘clam-digger’ position (also known as the ‘intrinsic plus’ position or ‘position of safe immobilization’) with a dorsal half-plaster which will allow finger flexion and intrinsic IP joint extension to the limit of the splint. the affected digit can be buddy-strapped to an adjacent digit during active exercise. These proximal joint exercises are followed by gentle active combined (i. At the completion of the splinting period. 10. in the presence of persisting oedema. If the fracture has not been satisfactorily reduced.10). 10. Because dorsal hand oedema is often marked. Finger alignment Alignment of the fingernails is assessed to check any tendency toward rotation of the affected digit. Extensor lag Extensor tendon adhesion following surgery is quite common and can result in a temporary lag until tethering of the tendon to skin and bone is overcome. simultaneous PIP and DIP joint) interphalangeal joint flexion.9. These exercises are repeated 6 to 10 times at each session. Corrective procedures (i) Wedge osteotomy Dorsal angulation following transverse shaft fractures can result in prominence of the metacarpal head in the palm that causes pain when gripping. it may be difficult to place the MCP joints in maximum flexion (usually 80–90 degrees) at the initial cast application. Scar massage. Light activity is commenced following plaster removal. This to the dorsum of the forearm and hand will apply gentle compression to hand oedema and will allow unimpeded finger flexion and intrinsic IP joint extension to the limit of the cast (Fig. open reduction may be necessary. Oedema should be managed with Coban wrap initially. full IP joint extension. splint. If gentle passive/active exercise does not overcome MCP joint stiffness within the first 2 weeks. During interphalangeal flexion. The cast will therefore need to be replaced after several days when swelling has subsided. Exercises The patient should perform active shoulder and elbow exercises on an hourly basis during the 3 to 4 week splinting period. The main difference is that the postoperative splint can be removed for exercise sessions every few hours and can be discarded after 10 to 14 days when sutures are removed. The hand should be kept elevated for at least the 1st week. To help maintain digital alignment.Fractures of the hand 123 Figure 10. This deformity is also associated with a pseudoclaw due to shortening of the metacarpal. making flexion of the MCP joints difficult. will be to assume a hook grip where flexion is initiated at the IP joints whilst the MCP joints remain in extension. silicone gel compression and extrinsic extension exercises should be employed to address this problem. a lycra glove is fitted. a dynamic MCP joint flexion splint should be applied (Fig. 10.e. Following suture removal. a lycra compression glove is fitted if dorsal hand oedema persists. the digit is observed for any tendency to cross over an adjacent digit.

Treatment strategies vary considerably from centre to centre and include: (i) Figure 10. (a) Oblique fracture of the middle finger metacarpal. Crepe bandage support with immediate commencement of active movement. 2. .g. Neck fractures Metacarpal neck fractures usually involve the ring and little finger metacarpals and result from the forceful impact of the clenched fist with a solid object. (ii) Closed reduction and transverse percutaneous K-wire fixation of the fractured metacarpal to the adjacent metacarpal. closed intramedullary fixation using three pre-bent flexible K-wires (Foucher. is managed with a dynamic flexion splint. i. (b) Open reduction and internal fixation with compression screws. however the splint is removed every 2 to 3 hours during the day and gentle active exercise of all digits is carried out. Stiffness of the MCP joints that is not readily overcome with passive/active exercise. e. (ii) Rotation osteotomy Rotational malunion following spiral or oblique fractures can be addressed with a corrective osteotomy through the base of the metacarpal. Support splinting in the position of safe immobilization is used for 3 to 4 weeks. There is not universal agreement on the management of these fractures. (iv) Open reduction.11. 1995).124 The Hand: Fundamentals of Therapy (a) (b) Figure 10. problem can be addressed with an opening or closing wedge osteotomy.10. (iii) ‘Bouquet osteosynthesis’.e. lateral application of a minicondylar plate.

When the support splint is discarded after the 3rd week. buddy-strapping is maintained for a further 2 weeks. 1976). These exercises are carried out slowly within the limits of discomfort. When the immediate soft tissue response of pain and swelling has subsided after the first 2 to 3 days. Fracture dislocation of the little finger CMC joint is more common. Metacarpal head and base fractures 1. 10. Gentle active movement is then begun. 10. This can involve gentle flexion bandaging. the splint is first fitted. Full extension of the interphalangeal joints may not be achievable when .17) Closed reduction of spiral fractures of the proximal and middle phalanges is often lost through early movement. Stable – conservative treatment Fractures that are stable. Following splint removal.13). with its gentle extension force. A Capener splint is used if the flexion deformity is unresponsive to the neoprene stall. Transverse fractures of the proximal and middle phalanx are particularly amenable to closed reduction. 2. A short section of narrow Coban can be used for this purpose (Fig. A buddy strap can be used during active movement. usually 3 to 5 weeks following fracture (Fig. It should therefore be remoulded or replaced 3 to 5 days later. 10. gentle active interphalangeal joint movement is begun. The splint is removed every few hours for gentle active IP joint flexion and extension exercises. goes some way toward counteracting this problem. To help control fracture alignment. significant angulation (up to 70 degrees) can be accepted without compromising function (Holst-Nielsen. flexion splinting can be instituted when clinical union has been achieved. (ii) Spiral fractures (Fig. Digital oedema is managed with a single layer of Coban wrap (25 mm) which is applied in a distal to proximal direction. Coban wrap. non-union is rarely a problem. Some patients are unhappy over the loss of prominence of the metacarpal head although this is more a cosmetic rather than a functional consideration. 10. Treatment options include closed reduction with percutaneous K-wire fixation or open reduction and internal fixation. Base Base fractures of the index and middle finger metacarpals are rare. An alternative option is an osteochondral autograft taken from a toe. Comminuted intra-articular fractures can be difficult to treat with ORIF and in some cases immediate arthroplasty may be considered. Some surgeons believe that in the case of the little finger. Stiffness If interphalangeal joint flexion range is slow to improve or has plateaued. the commonest complication after phalangeal fracture is a PIP joint flexion deformity. (i) Transverse fractures Displaced fractures that are stable following reduction are splinted in the position of safe immobilization for 3 weeks. Maintenance of the digit in extension during splinting also helps avoid a flexion deformity. closed and non-displaced are treated with a finger splint holding the interphalangeal joints in extension for 3 weeks. the digit is buddy-strapped to an adjacent digit with nonstick strapping such as Velcro or a section of Coban.Fractures of the hand 125 Whatever treatment method is used. Head A fracture to the head of a metacarpal is rare and usually intra-articular.12). For this reason. Confirmation of skeletal integrity by the treating surgeon should be sought prior to the commencement of flexion splinting. a hand-based dynamic flexion splint or an IP joint flexion strap to gain the end Fractures of the proximal and middle phalanges 1. a neoprene fingerstall will effectively maintain extension while at the same time allowing IP joint flexion (Fig.2).14). The splint is removed every 2 to 3 hours during the day and 5 to 10 repetitions of combined IP joint flexion and extension movements are performed. Blocking the MCP joints in extension will help facilitate extrinsic flexor tendon pullthrough. these fractures are immobilized in a POSI splint for 3 weeks (See Figure 10. Associated problems Flexion deformity of the PIP joint As with any injury to the digits.

(a) This midshaft fracture of the middle phalanx of the middle finger is stable.12.126 The Hand: Fundamentals of Therapy (c) (a) (d) Figure 10. (b) This fracture was associated with soft tissue injury. non-displaced and was treated conservatively. (c) Stable proximal and middle phalangeal fractures are protected with a finger splint for 3 weeks. Digital oedema is treated with Coban wrap (25 mm). (b) . (d) Gentle active interphalangeal joint flexion and extension exercises are performed every few hours.

13. Age of the patient. . Length of immobilization. Functional outcome The final range of motion achieved will be determined by a number of factors. 1985). Figure 10.Fractures of the hand 127 Figure 10. Of these various factors. 2. 3.15. The patient with an underlying arthritic condition will be considerably more prone to stiffness. 4. The nature of the fracture and associated soft tissue injury. Excessive immobilization following fracture. The end range of flexion is achieved with an IP joint flexion strap. 2. A neoprene fingerstall is an effective measure for controlling and overcoming flexion deformity of the PIP joint. i. is also responsible for a poor outcome (Strickland et al. the most significant one is the age of the patient.e. Whatever method is used. Patients in the first two decades of life achieve significantly greater mobility than those beyond the fourth or fifth decades. These include: 1. tendon.e.14. Patient compliance and associated conditions. Unstable (i) Closed reduction and percutaneous K-wire fixation Shaft fractures that are potentially unstable can be addressed with percutaneous K-wire fixation for 3 weeks (Belsky and Eaton. range of flexion (Fig. beyond 4 weeks. 1982). Stiffness of the PIP/DIP joint(s) is addressed with a hand-based dynamic flexion splint.g. 10. i. e. arthritis.15). Coban wrap (25 mm) was used in this instance. nerve and vessel injury or skin loss.. These include Figure 10. care must be taken to apply only a gentle stretch which does not result in pain or swelling.

10. Figure 10. Irreducible fractures are treated with rigid internal fixation. Therapy (a) Splinting and early movement The hand is rested in a POSI splint for the first 3 to 5 postoperative days. oblique or transverse shaft fractures of the proximal and middle phalanges are best treated with rigid internal fixation. Ideally the fixation will be stable enough to allow early active movement several days after surgery. Figure 10. The potential problem of postoperative scarring following extensive soft tissue dissection is offset by the commencement of early active movement. the forearm-based splint can be replaced with a finger splint after about 5 days. This potentially unstable proximal phalangeal fracture was treated conservatively with splinting in the ‘position of safe immobilization’. Most fractures needing percutaneous pinning will require two pins for stability and to control rotation. The Luhr microfixation system was used to manage this unstable proximal phalangeal fracture. The lumbricals and interossei are the deforming forces in a transverse proximal phalangeal fracture. Gentle.17. spiral and oblique fractures that tend to rotate. The splint is worn between exercise periods. angulate or shorten. Use of the lower profile Luhr microfixation system has allowed easier wound closure and less interference with extensor tendon excursion (Fig.18). active stabilized movement of the interphalangeal joints is begun 2 to 3 days following Interosseous muscle Lumbrical muscle Figure 10.18. This form of fixation is augmented with a support splint holding the hand in the position of safe immobilization. Elevation is maintained and movement of the shoulder and elbow joints encouraged.16. . If pain and swelling allow.128 The Hand: Fundamentals of Therapy (ii) Rigid internal fixation Irreducible spiral.

Fractures of the distal phalanx The thumb and middle finger distal phalanges are the most common fracture sites in the hand. Support splinting is maintained for 3 to 5 weeks. 2. a neoprene fingerstall or silicone-lined fingerstalls. A stable fracture can be splinted in a mallet-type splint for 3 to 4 weeks. desensitization exercises are begun. Scar compression is also provided by Coban wrap. The finger splint is moulded over the Coban which is liberally coated with powder to prevent the heated material from sticking to the wrap. Most of these fractures are sustained in the workplace.g. these fractures can be treated conservatively for 2 to 3 weeks with a small thermoplastic splint which allows motion of the PIP joint. Dressings should be nonstick. Figure 10. 3. The distal phalanges of the thumb and middle finger are the most common fracture sites in the hand. This manoeuvre is repeated every few hours throughout the day. the finger splint should be replaced or remoulded several days later when swelling has further subsided. a hand-based dynamic flexion splint can be applied with the permission of the treating surgeon.19. (c) Stiffness Stiffness of the PIP and DIP joints can be addressed with gentle flexion bandaging after the first two weeks. e.19). To help alleviate hypersensitivity. particularly if the injury is an open one. Tuft These fractures invariably result from a crush injury and are often associated with laceration to the pulp and/or nail matrix. Unless displaced. The effectiveness of flexion bandaging is augmented by immersing the hand in warm water for the 15 min that this position is maintained. soft tissue scarring is addressed with oil massage. Treatment Treatment of these fractures involves repair of the nail matrix together with a short period of DIP joint support (7 to 10 days) to provide symptomatic relief. Fractures of the distal phalanx can occur at three levels: 1. (b) Scar management Following suture removal. If maximum extension of the IP joints cannot be achieved at the initial splinting session. On healing of the pulp. Displaced fractures are stabilized with a Herbert screw or K-wire. Coban wrap (25 mm) can be applied over the dressing to reduce oedema. Opsite Flexifix is applied over the sensitive area. Closed injuries often result in a subungual haematoma which should be decompressed to provide relief of pain (Fig. . and can be held in place with gentle Coban compression. Base Fractures to the base of the distal phalanx are often unstable and may require fixation. Where necessary. 10. The tension of the bandage should be low and not result in pain.Fractures of the hand 129 surgery. All these materials allow interphalangeal joint flexion. Adaptic. Shaft Shaft fractures are either transverse or longitudinal. Movement of the more proximal joints is commenced immediately.

closed reduction alone is difficult because the pull of abductor pollicis longus tends to cause the base of the metacarpal to slide down the inclined plane of the trapezium. cold sensitivity. The fracture occurs at the medial volar lip which remains attached to the metacarpotrapezial ligament while the metacarpal shaft is subluxed radially and dorsally by the tendon of abductor pollicis longus. Rolando’s fracture (Fig. Closed reduction In general. or where the fragment is greater than 25 to 30 per cent of the articular surface. 1952). or through the metacarpal shaft and into the fractured fragment. (i). It usually involves less than a third of the articular surface. i. The surfaces of the trapezium and thumb metacarpal resemble two interlocking saddles. Fractures to the thumb Thumb fractures tend to be much more forgiving than finger fractures because of the compensatory movements afforded by the mobility of the thumb at its basal joint. e.or T-shaped.e.20.20) The Rolando fracture is also an intra-articular fracture and appears Y. particularly if the fragment is less than 15 to 20 per cent of the articular surface. inserted between the thumb and index metacarpals.g. 1. Contact sports can usually be resumed after 1 month.130 The Hand: Fundamentals of Therapy Fractures of the distal phalanx are frequently associated with some long-term problems which include: numbness. A temporary plaster is (ii) Open reduction and internal fixation Where the patient has greater demand placed on the hand. The thumb metacarpal is the second most commonly fractured metacarpal with 80 per cent of fractures occurring at its base. Anatomic Figure 10. 10. fitted for the first few days after which the plaster is remade or a thermoplastic splint fitted to accommodate reduction of oedema. The splint is worn in ‘at risk’ situations for a further 2 to 3 weeks. Bennett’s fracture This intra-articular fracture was first described in 1882 by E. Aftercare The thumb is protected in a forearm-based thumb spica for the first 10 to 14 days following surgery. Aftercare The thumb is immobilized in a forearm-based thumb spica for one month. When the integrity of this joint is lost through injury or degenerative arthritis. In a low demand patient. Rolando’s fracture is a comminuted intra-articular fracture of the base of the thumb metacarpal. hypersensitivity and abnormal nail growth. This configuration allows motion in two planes. Gentle active movement of all thumb joints is begun 2 to 3 days after surgery. H. a professional athlete. Bennett and is really a fracture subluxation. A true lateral view of the CMC joint must be obtained to establish joint congruity (Billing and Gedda. 2. open reduction and internal fixation with lag screws is preferred. The splint should maintain the first web space and the thumb should be aligned with the index and middle fingers. a removable splint is used for a further month of protection in between exercise sessions. percutaneous K-wire fixation and plaster immobilization for one month may be indicated. Pin fixation can be intermetacarpal. thumb function is compromised. Following K-wire removal after 4 weeks. . The thumb IP joint should be left free to move.

Ngai.. R. A. Williams & Wilkins. Botte. W.. Assoc. C. Hand Surg.. Rose. J. Callahan. Dennys. (1970). A study of the healing of one hundred consecutive phalangeal fractures. 775. (1997). Gellman. 18A.21).) pp.) pp. 17. C. (1995). reduction is usually not achievable with this fracture which is usually managed by open reduction and internal fixation. K. R.. L. P. 387–94. M. W. 10. E. ed. (1935). Orthop. W. (1994). R. W. J. J. Statistical review. 2. Open reduction and internal fixation method for fractures at the proximal interphalangeal joint. F. Melone. A. tension band wiring or plate fixation. 290–3. and Cox. 16–24. Simonetta. S. G. Plast.. A. N. Can. (1962). Screw fixation of Bennett’s fracture. L. B. J. 14A. 10. (1989). N. (1996). Clin.Fractures of the hand 131 Figure 10.. C. Mackin and A. J. 11. Churchill Livingstone. The use of ‘A. (1992). So. (1982). D. Rev. Hand Surg. R. Ip. E. E. and Meydrech. ed. C. Management of nonarticular fractures of the hand. M. Open hand fractures: an analysis of the recovery of active motion and of complications. F. (1995). J.. 779–92. A prospective study on 284 digital fractures of the hand. K. Gonzalez. Hand Clin. (1992). R. Hastings. Jr. C. . 239–50. 491–501. J. and Jupiter. Freeland. Open reduction and internal fixation of metacarpals and phalanges. Saunders. M. G. Igram. K... Pun. Fractures of the hand. and Wilson. A. (1993). eds) pp.21. Orthop. Fractures of the hand. Meyer. D. W. Orthop. 20A. M. C. Tubiana. S. Freeland. 86–90. Aftercare is as for ORIF following a Bennett’s fracture. F. A.. F. References Belsky. Clin. (1985). Holst-Nielsen. ‘Bouquet’ osteosynthesis in metacarpal neck fractures: a series of 66 patients. J. Scand. J. Hand Surg. Intramedullary nailing of proximal phalangeal fractures. 99–113. M. 4. Foucher. Gelberman. Chow. E. Reconstr. L.. and Flynn. 265– 73. Techniques of open reduction include: multiple K-wires. K.’ plates in the hand. ed. Orthop. Intra-articular fractures of the basilar joint of the thumb. In The Hand (R. Hand Surg. J. C. J. A. A.. B. H. D. Steichen. 474–81. and Abrams. Bruce Conolly. Opgrande.. Duncan. and Eaton. L. 790–5. I. 17. Mosby. 91–109. 194–201. Y. Bone Joint Surg. O. North Am. using an L..) pp.. 471–6. R. 27. Clin. DeBartolo. L. D.. P.. Med. Hand. In Rehabilitation of the Hand: Surgery and Therapy (J.. 20A (Suppl. In Atlas of Hand Surgery (W. F. and Rider. F.. L.. E. 808–812. Billing. (1983). 5.. Hurst. Luk. L. L. Acta Radiol. B. (1993). von Schroeder. 8. H. B.. B. In Techniques in Hand Surgery (W. and Westphal. 421–35.. N. Rigid fixation of phalangeal and metacarpal fractures. Howe. L. H. (1988). R. Hargreaves. and Ng. North Am. Kleinman. Smith. 14.or T-plate (Fig. T. Fractures of the hand. and Gedda. W. 353–75. J. 86. Zinberg. F... (1986). Butt. W.. J. Davis. 317–9. Phalangeal fractures: factors influencing digital performance. 276. I. 43–5. Hunter. and Benoist. (1995). II. 39–50. D. (1976). F. Closed percutaneous wiring of metacarpal and phalangeal fractures... Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active movement. C. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. M... T. K. and Hall. K. Hand. Rolando’s fracture requires open reduction and internal fixation. Blair. J. W... J. H. J. Hand Surg. J. Hand Ther. O. 38. E.. M. Chan. Crosby. Subcapital fractures of the four ulnar metacarpal bones..). (1952). F. Roentgen examination of Bennett’s fracture. H. Further reading Breen. M. Strickland. Hand Clin. Jabaley.

Orthop. and Freeland. Use of the minicondylar plate in metacarpal and phalangeal fractures. Moberg. In Green’s Operative Hand Surgery. E. E. (1996). P.. J. J. B. Green. Scand.. 1235–50. Acta Chir. Jupiter. Chapman. N. Stern. (1988). The use of traction treatment for fractures of phalanges and metacarpals. (1999) Fractures of the metacarpals and phalanges. (D. A. In Operative Orthopaedics (M. A. Lippincott.) pp. A. . ed. and Silver. 341–52. Hotchkiss and W. Churchill Livingstone. C. P. 327. R. 38–46. E. 99. Fractures of the metacarpals and phalangeals. Clin. M. eds) pp.. Pederson. (1950). W. 711–71.132 The Hand: Fundamentals of Therapy Ouellette.

They are often regarded as trivial and by the time treatment is sought several weeks or months later. this shape varies from digit to digit. 11. Anatomy of the PIP joint The PIP joint is a ginglymus (or hinged) joint which moves in the sagittal plane and has a flexion range of approximately 100 degrees (Eaton. The thick collateral ligaments have a proper and an accessory component that are distinguished by their points of insertion. Combined with the accessory movements. Joint injuries are incurred frequently during sporting activities. The articular surface extends further palmarly than dorsally. ligament and tendon (Fig. whilst mirroring one another. The joint is comprised of three main anatomic components: bone. it is noted to have a trapezoidal shape. deformity and stiffness have become entrenched. The collateral ligaments are the primary restraints to radial and ulnar joint deviation. When the PIP joint is flexed to 90 degrees and the proximal phalanx is viewed endon.1). The collateral ligaments are 2–3 mm thick and are Collateral ligament proper Accessory component Volar (palmer) plate Check-rein ligaments Accessory component Collateral ligament proper Volar (palmer) plate Figure 11. The volar plate forms the floor of the joint and is suspended laterally by the collateral ligaments. The articular surfaces. The head of the proximal phalanx is a convex bicondylar surface with an intercondylar groove that articulates with the biconcave base and intercondylar ridge of the middle phalanx. thereby favouring flexion. are not fully congruous. . The PIP joint is a hinged joint with a flexion range of approximately 100 degrees. the sequalae of pain. The support system of the PIP joint Capsular support for the PIP joint consists of tough collateral-accessory ligaments on the lateral aspect of the joint and a fibrous plate on the volar aspect. these slight variations in shape allow the digits to adapt to irregular shapes when power grip is applied (Fig.2). The width of the joint is twice its vertical height and this contributes significantly to joint stability. This lack of complete congruity allows slight lateral and rotational motion.1.11 Joint injuries of the fingers and thumb Joint and ligament injuries occur most frequently in the proximal interphalangeal (PIP) joints of the fingers and the metacarpophalangeal (MCP) joint of the thumb. 11. 1995).

134 The Hand: Fundamentals of Therapy I II III scar. Support to the dorsum of the joint is minimal. adherence of the volar plate or prolonged immobilization will produce a major restriction to joint motion. Distally it is a dense fibrocartilaginous structure with periosteal attachment at the central base of the middle phalanx and dense lateral attachments at the corners. IV Figure 11.3). consisting mostly of the thin.2. it is noted to have a trapezoidal shape. type of deformity and restriction of joint motion. . 3. Pain. Physical examination Observations during the physical examination should include: degree of swelling. This latter portion is the more flexible and concertinas in the end range of flexion. Supplementary joint stability is provided by the lateral bands. The collateral ligament proper inserts on the volar base of the middle phalanx while the accessory portion of the ligament attaches to and suspends the volar plate and tendon sheath. Injury to the PIP joint is invariably accompanied by a flexion deformity. They prevent hyperextension of the joint yet are sufficiently flexible to fold upon themselves during maximum joint flexion. Signs and symptoms of PIP joint injury 1. When the PIP joint is fully flexed. The two ‘tails’ are check-rein ligaments and are firmly anchored to the volar periosteum of the proximal phalanx. 11. When the PIP joint is flexed to 90 degrees and the proximal phalanx is viewed end-on. Proximally the volar plate is much like an inverted ‘U’ and resembles a swallow’s tail. combined with the slight lack of joint congruity that facilitates lateral and rotational motion. the base of the middle phalanx sits firmly in this recess.. Deformity (usually PIP joint flexion deformity) (Fig. The thickness of the distal volar plate increases the mechanical advantage of the flexor tendons in the initiation of interphalangeal joint flexion. allows the digits to adapt to irregular shapes when power grip is applied. They arise from the condyles of the proximal phalanx and pass in an oblique and volar direction. 4. This variation. 1986). Obliteration of this space by Figure 11.g. When present for weeks or months it becomes fibrotic and results in periarticular thickening that gives the joint a fusiform appearance. semi-elastic extensor mechanism as it blends with the delicate dorsal capsule.3. Assessment 1. The volar plate forms the floor of the joint. Swelling. did the joint dislocate laterally or dorsally and was it reduced at the time? 2.4). 2. Stiffness of interphalangeal joints. History The history should include the mechanism and recency of injury. e. It is here that the major vincular systems to the flexor tendons originate. Acute swelling is usually soft and easily indented. This shape varies from digit to digit. 11. the major restraint to lateral stress (Kiefhaber et al. the transverse retinacular ligament and the oblique retinacular ligament. providing maximum stability. bone spur. The joint is gently palpated for specific areas of tenderness (Fig. The proximal end of the volar plate has a central membranous portion which bridges the retrocondylar recess.

e about 20 degrees if volar plate involvement is suspected or in maximum extension if the injury is regarded as a sprain of the collateral ligaments. this will indicate complete disruption of the collateral ligament. Lateral injury to the PIP joint Injuries to the collateral ligaments occur more frequently on the radial aspect of the joint and often have some involvement of the volar plate. They result from unilateral stress applied to the Figure 11. In the acute phase. A dorsal finger splint provides support during the first few postinjury days. its prolonged presence will prevent movement and will result in adherence of joint structures. This is applied with great care to avoid lateral stress to the PIP joint. X-ray examinations Posteroanterior (PA) and true lateral views of the hand should include views of the digit alone to avoid superimposition of the other digits. Treatment Oedema control and protective splinting Figure 11. . a metacarpal block will be required prior to this assessment.4. the PIP joint is placed in slight flexion. these injuries are painful and accompanied by significant oedema which effectively ‘splints’ the joint in a semi-flexed position. If the lateral stress test produces a deformity of greater than 20 degrees. Stiffness of both IP joints is common. This may not be achievable on the first visit. If involvement of the volar plate is suspected. A single layer of 2. These injuries are managed conservatively following reduction. Where the injury is acute and accompanied by pain. the exception being an unstable fracture-dislocation. Note the absence of skin creases over the PIP joint. otherwise the IP joints are splinted in maximum extension. 3. 4. Most dislocations can be treated conservatively. A ligament injury can be regarded as a sprain if the injured joint has sufficient capsular support to prevent displacement under appropriate stress. i. laterally or volarly.5 cm Coban wrap is applied to the digit in a distal to proximal direction. The splint is worn for the first 3 to 7 days following injury to allow Dislocation of the PIP joint The PIP joint can dislocate dorsally. Joint stability If a serious fracture has been excluded. and later with fibrotic periarticular thickening. active and passive joint stability is assessed. The injured PIP joint usually presents with soft swelling in the early stages after injury. A single layer of Coban is applied to the swollen digit.Joint injuries of the fingers and thumb 135 extended digit. The finger is then rested in a thermoplastic finger splint in slight PIP joint flexion. While the oedema has some protective role.5.

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Figure 11.7. Intrinsic stretches are performed by holding the MCP joints in the extended position and gently passively flexing the IP joints. This manoeuvre maintains the length of the lateral bands and oblique retinacular ligament. Figure 11.6. Hourly active stabilized IP joint flexion/extension exercises are performed through the Coban wrap.

pain and swelling to settle. This period may be extended if there has been complete rupture and significant pain and swelling (Fig. 11.5). Exercises Gentle active stabilized IP joint flexion/extension exercises are then commenced through the Coban wrap. These exercises are performed on an hourly basis with 5 to 10 movements initially. As tolerance to exercise improves, the number of movements is increased. Movements are carried out gently and slowly and the end range position should be held for several seconds before the movement is repeated (Fig. 11.6). Buddy-strapping After the splinting period, the injured finger is taped to an adjacent digit to provide lateral support during activity. Coban wrap and Micropore tape are both suitable for this purpose. A buddy-strap fashioned from Velcro can be used if the joints of the two adjoining fingers are relatively level. Intrinsic stretches Adherence of the lateral bands or oblique retinacular ligament can occur following injury to the collateral ligaments. To help prevent contracture,

intrinsic stretches are incorporated into the exercise programme. The intrinsic muscles are stretched by holding the MCP joints in the extended position while passively flexing the IP joints (Fig. 11.7). This is followed by stabilized active DIP flexion exercises with the PIP joint held in extension; this manoeuvre places the oblique retinacular ligament on maximum stretch. Overcoming PIP joint flexion deformity The first line of defence in correcting and controlling a PIP joint flexion deformity is a neoprene fingerstall. The stall can be sewn in minutes and is easily applied and removed. It controls oedema, allows flexion and frequently reduces joint pain (Fig. 11.8). To gain the last 20 degrees or so of extension range, a Capener splint may be required (Fig. 11.9). Efforts to overcome the flexion deformity need to be balanced with consistent attention to regaining passive/active flexion range at both IP joints. The patient is advised to wear the neoprene stall around the clock other than when performing hourly flexion exercises. Flexion strapping of interphalangeal joints Where IP joint stiffness is marked, gentle flexion bandaging prior to active exercise is recommended. An IP joint flexion strap made from neoprene is used when the patient has achieved sufficient flexion range to hold the strap in place. Coban wrap (25 mm) or Microfoam tape also make effective flexion straps (Fig. 11.10). The tension of the strap

Joint injuries of the fingers and thumb

137

Figure 11.8. A neoprene fingerstall is the first line of defence in overcoming a PIP joint flexion deformity. As well as exerting a gentle extension force, the stall will reduce oedema and frequently relieve joint pain. Active flexion exercises can be carried out with the stall in place.

Figure 11.10. Frequent use of an IP joint flexion strap throughout the day will help restore flexion range. The strap can be made from neoprene/velcro, or alternatively, Coban wrap or Microfoam tape which is shown here.

these devices are left off for several consecutive days. Use of the neoprene stall during the day allows unimpeded use of the digit. A Capener or static splint can then be used at night.

Dorsal dislocation of the PIP joint Dorsal dislocation of the PIP joint is the most common dislocation in the hand. It results from hyperextension of the joint and is usually associated with a distal rupture of the volar plate from the base of the middle phalanx with or without an avulsed bone fragment (Fig. 11.11).

Figure 11.9. A dynamic Capener splint may be needed to overcome the last 20 to 25 degrees of deformity.

should be sufficient to provide a gentle stretch without causing pain or restricting circulation. It is left in place for 10 to 15 min every few hours during the day. Resisted exercises and activities are delayed until at least 6 weeks after injury. Maintenance of home programme Ligaments are notoriously slow to heal. Persisting pain, stiffness and recurrent joint swelling are common. The patient is therefore encouraged to maintain the exercise and splinting programme for some months following injury. Even when flexion range has been restored, the propensity for recurrent flexion deformity is great. Intermittent extension splinting by way of a neoprene fingerstall, Capener or static finger splint should be maintained until the joint no longer ‘relapses’ when

Collateral ligament proper

Accessory ligament Ruptured volar plate

Figure 11.11. Dorsal dislocation of PIP joint. The collateral ligament proper remains attached and intact and usually provides stability after joint reduction. The accessory portion of the collateral ligament remains with the volar plate which ruptures from the base of the middle phalanx, either on its own or with a small avulsion fragment.

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Treatment The majority of these hyperextension and dorsal dislocations injuries can be reduced satisfactorily and treated conservatively. The PIP joint is splinted in 25 to 30 degrees of flexion for 1 to 2 weeks. Gentle active exercise is commenced 2 to 3 days after injury when the initial swelling and oedema have subsided. Oedema is managed with Coban wrap. Following removal of the splint, the digit is buddy-strapped to an adjacent finger for support. Extension splinting is delayed until the 5th week and consists of the same regimen as that which has been described for lateral joint injury.

Figure 11.13. Volar plate advancement restores a smooth fibrocartilaginous surface to the base of the middle phalanx. The volar plate is sutured to the base of the middle phalanx using a pull-out suture. A K-wire holds the reduced joint in 25 to 30 degrees of flexion for three weeks.

Unstable fracture-dislocation of the PIP joint
Unstable fracture-dislocations are those where joint congruity has not been established following closed reduction or where more than 40 per cent of the volar articular surface is fractured (Fig. 11.12). Surgery Volar plate advancement (Bilos et al., 1994) restores a smooth fibrocartilaginous surface to the base of the middle phalanx. The joint is exposed and assessment is made regarding the possibility of reduction and fragment fixation. A single, large fragment can be reduced and held with one or two K-wires. Where the fracture is significantly comminuted, the fragments are debrided and the distal portion of the palmar plate is advanced 4–6 mm and sutured to the base of the middle phalanx using a pull-out suture. A K-wire holds the reduced joint in 25 to 30 degrees of flexion for 3 weeks (Fig. 11.13).

Aftercare Gentle DIP exercises are practised throughout this period. Following removal of the K-wire, the joint is maintained in the same degree of PIP joint flexion with a dorsal blocking splint for another week and gentle active PIP joint flexion exercises are begun. Unforced active PIP joint extension is then commenced at week 4. Any residual flexion deformity is overcome with gentle extension splinting from the 5th week onward.

Intra-articular fractures
Apart from hyperextension injuries, intra-articular fractures of the PIP joint (Morgan et al., 1995) can result from impaction injuries where the base of the middle phalanx is driven over the head of the proximal phalanx or pilon fractures where there is disruption of both the dorsal and volar articular

Figure 11.12. Radiograph showing dorsal dislocation of the PIP joint of the index finger with a significant articular fracture of the base of the middle phalanx.

Figure 11.14. Pilon fracture of the left little finger sustained whilst playing cricket.

Joint injuries of the fingers and thumb

139

(a)

(b)

(c)

(d)

Figure 11.15. (a) The arcuate splint provides dynamic traction whilst allowing early movement. (b) Exercises are performed by the patient on an hourly basis. (c) Radiological appearance of the PIP joint at completion of traction period, i.e. at 6 weeks. (d) Active flexion range at completion of traction period.

margins and depression of the central articular surface (Stern, 1991) (Fig. 11.14). Surgical management of these can include skeletal traction using an external fixateur or open reduction and internal fixation (Dennys et al., 1992) (Fig. 11.15). Treatment of these complex injuries has a significant failure rate and PIP joint fusion, implant arthroplasty or elective amputation may be indicated.

Technique This procedure is performed under selective peripheral nerve block. The joint is approached through a midaxial incision and the collateral ligaments and/or volar plate are released. If necessary, limited extensor and flexor tenolysis is performed. Aftercare

Corrective surgical procedures of the PIP joint
The most common complication of injury to the PIP joint is stiffness. Where adequate functional motion in either flexion or extension range has not been achieved despite a protracted splinting regimen, surgical release (arthrolysis) is considered.

Postoperatively the joint is splinted into the corrected position and active movement is begun within a day of surgery. Exercise sessions should be short and performed 1 to 2 hourly. Analgesia may be required for the first few days. Coban compression is used to control digital oedema. Dynamic splinting is reinstituted after the first week when the postoperative soft tissue response

Alternative salvage procedures include PIP joint arthroplasty or fusion. Adductor pollicis and the first palmar interosseous insert into the ulnar sesamoid (Kaplan and Riordan. it is usually assumed that there has been a complete ligament rupture. tenderness and swelling along the ulnar border of the joint. thereby impeding ligament healing. surgical repair is indicated. Distal tears at the insertion of the ligament are more common than proximal tears. Flexor pollicis brevis and abductor pollicis brevis insert into the radial sesamoid. Diagnosis Diagnosis is generally made on a clinical basis. It is important to distinguish between a partial and complete ligament rupture (Stener lesion). 1953). . Volar stability is provided by the volar plate together with the thenar intrinsic muscles. 1971). Treatment for complete rupture of UCL Because the results of conservative treatment for complete rupture are unpredictable. Lateral stability of the joint comes from collateral and accessory ligaments. although diagnostic ultrasound and MRI (Harammati et al. Significant displacement will indicate retraction of the ligament and a large displaced fragment involving the articular surface will require open reduction and internal fixation. Intermittent use of the splint is maintained for a further 2 weeks with the splint being removed every few hours for gentle active motion. Partial tears of the ulnar collateral ligament are managed with a hand-based thumb splint which holds the MCP joint in slight ulnar deviation and flexion. Paradoxically. The ulnar collateral ligament (UCL) is injured 10 times more frequently than the radial collateral ligament (Moberg and Stener. Normal unrestrained use of the thumb is delayed until 12 weeks following injury. 11. a complete rupture will often be less painful than an incomplete one. Radiographs are taken in 3 planes to assess the base of the proximal phalanx for avulsion fracture. Full mobility of the distal thumb joint is maintained during this time.140 The Hand: Fundamentals of Therapy has subsided. 1992) (Fig. Its main movement is flexion-extension but it is also capable of some abduction-adduction and rotational movement.16). Figure 11. Unlike the finger PIP joints. The tension of the splint should initially be low to gauge joint response. Dynamic splinting may need to be maintained for several months to prevent recurrence of the contracture.16. 1995) can help confirm the diagnosis where necessary. Thumb joint injuries Anatomy of the thumb MCP joint The MCP joint of the thumb has features of both a condyloid and ginglymus joint (Eaton. The thumb MCP joint differs from the finger MCP joints by having a radial and an ulnar sesamoid in the volar plate between which passes the FPL tendon. the MCP joint of the thumb has no flexor sheath proximal to the volar plate and also has no check-rein ligaments. Where 30 degrees or more of joint laxity is present.. These procedures and their aftercare are discussed in the chapter on ‘Arthritis’. 1984). Signs and symptoms of UCL injury include bruising. Treatment of stable ligament injury Partial tears are splinted continuously for 4 weeks in a hand-based thumb splint which holds the MCP joint in slight ulnar deviation and flexion (Campbell et al. Ulnar collateral ligament injury This injury is commonly referred to as ‘skier’s thumb’ and results from forced abduction of the MCP joint. interposition of the adductor expansion will prevent the avulsed ligament from making contact with the rupture site. Injury to UCL may be associated with an avulsion fracture where the ligament inserts onto the ulnar base of the proximal phalanx. Where the rupture is complete..

Hand Surg. ed. Spinner. E. Saporiti. J. 772–808.... J. J. In Green’s Operative Hand Surgery (D. (1990). and Eaton. Surgical management of chronic ulnar collateral ligament insufficiency of the thumb metacarpophalangeal joint. 106. Splinting of the MCP joint is continuous for the first 4 weeks of immobilization.. Bowers. 16A. C. Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active movement. M. ( 1993). Skeletal Radiol. The proximal interphalangeal joint volar plate. and Stener. and Knutson. 17A. 385–9. J. E.. Rev. K-wires or a small screw. O. J. Green. E. References Bilos. interosseous wire. 5... Acta Chir. (1995).Joint injuries of the fingers and thumb 141 Surgery A ‘lazy-S’ incision is made over the dorsum of the joint. P. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint–biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Glickel. Vender. 20B. Feagin.. J.. 58–64. G. 512–7. Redding. 583–8. T. Fractures and dislocations of the hand. The adductor aponeurosis is identified and incised parallel to EPL. B. (1995) Dynamic digital traction for unstable comminuted intraarticular fracture-dislocation of the proximal interphalangeal joint. Ulnar collateral ligament injury of the thumb. Heyman.. J. E. G. Duncan. 149–54. 20A. Z. et al. Delaria. J. II. 166–86. Orthop.. Morgan. N.) pp. Lippincott.. 29–30. J.. 20. A. (1994). S. and Akelman. et al. W.. Diagnosis. 18A. Hand Surg. H. (1992)... 19A. the splint is removed every few hours and gentle MCP joint exercises are carried out.. Orthop. J. N. D. 229–37. (1956). S. Gordon. P. I. P. C. (1999). Scand. Hand Surg.. O. Hand Surg. 565–73. 385–448. Cooney. Am. (1953). Care is taken to protect the superficial radial nerve. Evarts. N. Moberg. J. The treatment of chronic flexion contractures of the proximal interphalangeal joint. et al.. MRI of the Stener lesion. Gelberman. J.. Pederson. and Cox. P. Frykman. 160–4. (1995). Acute open reduction and internal fixation of proximal interphalangeal joint fracture dislocation. Churchill Livingstone. a direct repair is made with interrupted non-absorbable sutures. 844–50. Smith. Mosby. Hand Surg. A. Dynamic external finger fixator for fracture dislocation of the proximal interphalangeal joint. The articular surface of the joint is examined. P.. eds) pp... P. Clin. (1984). Joint Injuries of the Hand. Green. Thomas. Jobe. 112..) pp. B. J. 20A. (1986). Further reading Abbiati. (1992). J. Some distal ruptures can be attached directly to the remaining tissue on the proximal phalanx. Campbell. T. A large bone fragment is anatomically reduced and attached by pull-out suture. The thumb. H. J. Churchill Livingstone. Extension block splinting. I. M. Inanami. (1981). Stern.. Fracture subluxation of the proximal interphalangeal joint by palmar plate advancement. A temporary transarticular K-wire is used if the repair seems a little tenuous. W. 625–30. (1991).) pp. ed. E. et al. N. Hand Clin. G. Klug. 189–96. 10. and Grood.. and Riordan. Eaton. Dowdle. B. Kiefhaber. and Hipp.. If there has been a midsubstance rupture. 292. Sports Med. 11A. 515–8. J. J. (1993). 24.. Injuries to the ligaments of the thumb and fingers.. B. and Johansson. During the next 2 weeks. S. G... H. Eaton. 6. Dobyns. Hand Surg. Ninomiya. M. Treatment with glove spica cast. Scand. Okutsu. et al. Z. In Kaplan’s Functional and Surgical Anatomy of the Hand (M. 16–24. R. Hurst. 116–7. (1992). (1971)... S. Harammati. R. 21. A clinical study of hyperextension injury. J. M. Gustilo. K.. M. R. D. J. M. E. B. Dislocations and ligament injuries in the digits. In Surgery of the Musculoskeletal System (C.. The distal thumb joint is mobilized throughout this period to avoid adherence of the extensor mechanism. Unrestrained use of the thumb is delayed until 12 to 16 weeks following repair. 51–66. Pilon fractures of the proximal interphalangeal joint. . Acta Chir. Arnold. Bonavolonta M. J.. Alton Barron. K.. D. L. Hand Surg. 165–71. G. Hand Surg. (1995). R.. Jacobson. treatment and prognosis.. Dislocations and ligamentous injuries of the hand... J. L. (1994). E. Green. (1993). Hand Surg. 661–9. P. J. P. J. Dennys. Hiller. and McElfresh. H. D. M. M. Where there has been a small bony avulsion fracture. ed. Hotchkiss and W. 77–81. A. The Founders Lecture: The narrowest hinge of my hand. and Wood. Kaplan. D. J. (1992). G. Hand Ther. C. In Fractures and Dislocations (R. Aftercare The joint is protected with a hand-based thumb splint for a total period of 6 weeks. pp. R. this is best excised and the ligament advanced to bone and anchored with non-absorbable thread or wire. Surgical repair of rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.. R. Lateral stability of the proximal interphalangeal joint. A. Stern.. Charles C. King.

J.. Wilson. Hand Surg.. L. 18A. A. and Hazen. and Eakins. 61–3. F. Hand Surg. eds) pp. Amadio. . M.. 377–94. D. et al. D. (1995). et al.. R. Horii. Mosby. Beard. Noszian. Orthner.. Management of joint injuries and intra-articular fractures of the hand.. E. Y. J. Callahan. E.. M. Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US. Radiology. Hand Clin. C. and Delprat. J. P. (1995). 777–86. I. 8. 194. Mansat. J. Sesamoid arthrodesis for hyperextension of the thumb metacarpophalangeal joint. J.. M. Kemp. Minamikawa.. 334–8. J. E. In Rehabilitation of the Hand: Surgery and Therapy (J. Stability and constraint of the proximal interphalangeal joint. M. (1995). 198–204. J. Contractures of the proximal interphalangeal joint. S.. Hunter. M. Dinkhauser.142 The Hand: Fundamentals of Therapy Tonkin. 20A. (1992). (1993). L. Mackin and A. A..

. 3. the ulna is 1–5 mm longer than the radius. The radiocarpal joint At this joint the distal radius articulates with the scaphoid and lunate bones. the scaphoid. This joint carries 80 per cent of the axial load of the forearm.1): 1.1. lunate and triquetrum.12 The wrist Peter Scougall The wrist is comprised of several articulations. the eight carpal bones and the distal radioulnar joint. the midcarpal joint. trapezoid. in ulna minus (or negative) variance the ulna is 1–6 mm shorter than the Anatomy The wrist is comprised of (Fig. i. Schematic drawing of the volar aspect of the wrist showing the radiocarpal joint. Biomechanical interpretation has undergone some modification recently and continues to evolve. The pisiform is a sesamoid bone that enhances the mechanical advantage of the most powerful motor in the wrist. 2. The distal radioulnar joint (DRUJ) The head of the ulna articulates with the shallow concavity of the sigmoid notch at the distal radius. 12. Hamate Pisiform Triquetrum Lunate DRUJ Trapezoid Trapezium Capitate Scaphoid Figure 12. the ulnar inclination of the distal radial articular surface is approximately 23 degrees (Fig. the trapezium. flexor carpi ulnaris. the anatomy and biomechanics of which are complex. In ulna plus (or positive) variance. capitate and hamate bones. The pisiform articulates with the triquetrum.e. i. The midcarpal joint The proximal carpal row. articulates with the distal carpal row. In ulna neutral (or zero) variance. Ulnar variance Ulnar variance (also known as Hulten’s variance) refers to the length of the ulna relative to the radius.2(a)). i. Radial tilt and inclination In the sagittal plane. the distal margin of the ulnar head articular surface is level with the medial corner of the radius.e. 12. In the frontal plane. the radius has a palmar tilt of approximately 11 degrees. Twenty per cent of the axial load of the forearm is carried through the ulnar carpus via the triangular fibrocartilage complex (TFCC).e.

disease is more common in people minus variance (Fig. with the exception of flexor carpi ulnaris. radiotriquetral. Clinically. The scaphoid bone spans both carpal rows anatomically and functionally. Intrinsic carpal ligaments connect the carpal bones to each other. triangular fibrocartilage complex. There is more play between the bones of the proximal row than the distal. RT. 12. 1999 with permission. (Copyright. K. eds) p.2. insert beyond the carpus onto the metacarpals. Carpal ligaments The relative importance of the carpal ligament system becomes apparent when it is remembered that all wrist tendons. radius. and Palmer. D. the carpus forms an arc which is the floor of the carpal tunnel. 932. (b) Ulna neutral (or zero) variance and ulnar inclination of distal radius. UT. this row being a relatively immobile unit that articulates with the metacarpals to form the carpometacarpal joints.3. A. (a) Palmar tilt of the radius. triquetrum. Volar wrist ligaments: RCL. triangular fibrocartilage. ulnotriquetral. Range and direction of movement of the carpal bones is determined by their articular arrangements and ligamentous attachments. Elizabeth Roselius. In Green’s Operative Hand Surgery (D. T. capitate. Fractures of the distal radius. radiocapitate. ulnolunate. radioschapholunate. In transverse section. acting as a restraining link that contributes to carpal stability. Ulna degenerative Kienboeck’s with an ulna positive variance is associated with changes in the ulnolunate joint. Carpal stability is provided by a complex intrinsic and extrinsic ligament system. RC. 1999. C. C T ECU sheath RCL RC UT UL TFC RT TFCC RSL Figure 12. RSL. L. extensor carpi ulnaris. Movement occurs not only between the carpal rows but also between the individual bones. Churchill Livingstone). It is a labyrinth of small bones and is flexible and compliant. Pederson. Green. . Hotchkiss and W. TFCC. N.2(b)). P. R. the most important of these is the (a) Ulnar inclination of distal radius Ulna neutral variance (b) Figure 12. Reproduced from Fernandez.144 The Hand: Fundamentals of Therapy The carpus The carpus does not move as a solid block. radial collateral ligament. ECU. UL. C. TFC. thereby depriving the wrist joint of their stabilizing influence.

The dorsal wrist retinaculum. The palmar wrist ligaments are thicker and more plentiful than the thinner dorsal ones. P. radioscaphoid. (Copyright. Wrist movements Wrist movement. 991. Dorsal wrist ligaments: DIC. Elizabeth Roselius with permission. H. the extrinsic ulnolunate and ulnotriquetral ligaments.5. R. 2. C. The TFC proper passes from the sigmoid notch on the radius to the base of the ulnar styloid process. Hotchkiss and W. R. Static stability of the DRUJ is provided by: 1. Triangular fibrocartilage and ulnocarpal V ligament (Copyright. The triangular fibrocartilage complex (TFCC). Churchill Livingstone. 12. It would appear that a strong palmar system is necessary to stabilize against wrist extension while less support is needed dorsally to stabilize against wrist flexion (Figs. excluding motion at the DRUJ. 1999.The wrist 145 Figure 12. 4. Dynamic stability is provided by the pronator quadratus. Reproduced from Fernandez. Congruent articular surfaces. K. extensor carpi ulnaris and flexor carpi ulnaris. N. 2. Elizabeth Roselius with permission.4). TFCC. vascular and structurally adapted to bear tensile loading.3 and 12. 3. Flexion/extension in the sagittal plane. The triangular fibrocartilage proper (TFC). The peripheral margins of the TFC are thick. D. dorsal intercarpal ligaments. The distal radioulnar joint.) Figure 12. Reproduced from Bowers. Radial/ulnar deviation in the frontal plane. A. Hotchkiss and W. Pederson. Green.4. In Green’s Operative Hand Surgery (D. 2. eds) p. Pederson. Extrinsic ligaments connect the carpal bones to the radius and ulna proximally and the metacarpals distally. N. occurs in two planes: 1. In Green’s Operative Hand Surgery (D. L. Fractures of the distal radius. it is triangular in shape. The interosseous membrane. eds) p. 3. RT. RS. 931. Churchill Livingstone. avascular and more suited to bearing compressive loads (Fig. radiotriquetral. The ulnocarpal complex. 1999. The triangular fibrocartilage complex (TFCC) This complex is comprised of: 1. The distal radioulnar joint Forearm rotation involves movement of the radius and hand about the ulnar head. Green. . 12. C. i. P.e.5). As the name implies. The extensor carpi ulnaris sheath. triangular fibrocartilage complex. W. and Palmer. The central portion is thin.) scapholunate (S-L) ligament.

particularly where the scaphoid or hook of hamate are involved. (iv) Magnetic resonance imaging (MRI) Magnetic resonance imaging can be used to assess certain ligament injuries and is the best investigation for the assessment of bone vascularity. Kienboeck’s disease. Forearm supination and pronation ranges between 80 to 90 degrees when assessed from the midrange position with the elbow flexed to 90 degrees. the first two thirds of movement occur at the radiocarpal joint. Assessment of the wrist 1. If the diagnosis remains unclear after thorough clinical assessment and plain X-ray. the remaining third at the midcarpal joint. (ii) Bone scan This is a sensitive although non-specific investigation for suspected bone injury. this area is palpated last. Unless this can be achieved and maintained. weakness and finally. Investigations (i) X-rays Many injuries can be diagnosed by plain X-rays. (iii) Tomography Tomography can define the anatomy of the injury more accurately than plain X-ray. the first half of motion occurs at the midcarpal joint and the second half at the radiocarpal joint. Two days after injury. e. Factors affecting outcome Outcome will also be influenced by the patient’s age and health status. Was the injury associated with a ‘snapping’ or ‘popping’ sound or sensation? Does the wrist ‘give way’ during activity? Where and when is pain present? What factors aggravate or relieve pain? Note should be taken of the patient’s expectations and physical demands in relation to occupation. problems such as malunion. where appropriate. Ask the patient to point to the most painful area. (v) Arthroscopy Arthroscopy has become an increasingly useful tool in recent years for the assessment and treatment of many wrist conditions including ligament injuries. comminuted fracture involving young. 3. A low velocity fracture in an elderly person with osteoporosis is a completely different injury to a high speed. Fractures of the distal radius Fracture of the distal radius is a common and often complex injury. sporting and leisure pursuits. History Assessment is made of the mechanism of injury and the force involved. Compare range of motion and grip strength with the contralateral side. articular cartilage defects and intra-articular fractures.g. Check for generalized ligamentous laxity and perform specific tests to assess stability. The choice of treatment will depend on the individual requirements of the patient and the complexity of the injury. Incongruity or instability of the DRUJ or ulnar impaction syndrome are other potential problems. plain X-rays can appear normal while a bone scan will be positive. e. fracture of the scaphoid. strong bone.g. angulation. During wrist extension. post-traumatic arthritis. Radial and ulnar deviation occur primarily at the radiocarpal joint. the Watson scaphoid shift test. Special views may need to be requested.g. a considerable range of motion occurs from radial deviation and extension to ulnar deviation and flexion. other investigations can be useful. Wrist flexion usually ranges between 75 and 90 degrees. shortening and loss of radial tilt will result in wrist pain. depending on the suspected pathology (see each section for details). stiffness. The ultimate functional result will depend on accurate anatomic reduction. During wrist flexion. Range of motion can vary considerably among individuals. Bone healing and fracture non-union is more apparent than on plain X-ray. radial deviation between 15 and 20 degrees and ulnar deviation between 35 and 40 degrees. extension between 70 and 80 degrees. Examination Look for swelling or deformity. Total range of forearm rotation is 150 to 190 degrees at the DRUJ proper and 260 degrees at the hand. e. Overenthusiastic treatment of the first can be just as detrimental as ‘under-treatment’ of the second.146 The Hand: Fundamentals of Therapy When these movements are combined. 2. Fractures in older patients are generally treated less ‘aggressively’ than those in young adults although treatment decisions should be based on the physical requirements of the patient rather .

1995.) . G. with permission.) Figure 12.6. In Rehabilitation of the Hand: Surgery and Therapy (J. falls from a height or from a motorbike at speed. The ulnar styloid process may be avulsed (Fig. Mosby. and Kropp. with permission.) Figure 12. Fractures and traumatic conditions of the wrist. Callahan. eds) p. 1995. Assessment of distal radial fractures 1. Mackin and A.e.7). D. E. E. K. History How did the injury occur and what force was involved? High velocity injuries. expectations and hobbies of the patient. Mackin and A. Vascular injuries are rare after distal radial fractures. M. 3. The opposite wrist is X-rayed for comparison. Callahan. e. A CT scan may define the anatomy of intra-articular fractures better than plain films. eds) p. M. Classification of distal radial fractures The more commonly used eponyms for the classification of distal radial fractures include: 1. activity level.The wrist 147 than simply on age. Mackin and A. E. Tendon injuries are possible. G. It is usually impacted. E. 2. i. The patient The treatment plan must take into consideration the age. J.8. 322. Hunter. J. D. 12. and Kropp. Callahan. mitigate against an enthusiastic operative approach. W. lateral and oblique views). The distal fragment is shifted and tilted dorsally and radially. eds) p. W. Ulnar nerve injury is rare. general health. Acute carpal tunnel syndrome may occur and occasionally. as is compartment syndrome (although this can be caused by a cast which is too tight). Fractures and traumatic conditions of the wrist. 12. extraarticular distal radial fracture with volar shift and tilt (Fig. (Frykman. Colles’ fracture with dorsal tilt of the distal fragment (Frykman. with permission.6). the median nerve may even be divided.7. Hunter. occupation. Hunter. Soft tissues Open fractures require urgent surgical debridement. E. J. Smith’s fracture This is a true reversed Colles’ fracture. In Rehabilitation of the Hand: Surgery and Therapy (J. D. G.g. Mosby. Smith’s fracture with volar tilt of the distal fragment (Frykman. 322. In Rehabilitation of the Hand: Surgery and Therapy (J. 320. W. Fractures and traumatic conditions of the wrist. Mosby. however. K. The fracture Adequate X-ray views are essential (posterioranterior. Figure 12. Severe osteoporosis and serious illness do. K. 2. 4. E. Colles’ fracture This describes a transverse extra-articular fracture of the distal radius less than 2. This is an intra-articular unstable fracture with either volar or dorsal fragment displacement. and Kropp. Barton’s fracture-dislocation (dorsal). M.5 cm from the wrist. 1995. involve greater soft tissue swelling and a higher risk of associated injuries.

incomplete articular and radial shear fractures if an acceptable reduction is achieved following closed manipulation. i.e. (1990) whose classification is shown below: Type I – non-articular.. undisplaced. Rayhack. It is extra-articular or intra-articular. these classifications include the ulna and DRUJ.. The limb is elevated and finger. Type IVB – intra-articular. Contemp. Type II – non-articular displaced. Fernandez and Cooney et al.9). 21. elbow and shoulder movements are commenced.9. Unlike earlier descriptions of radial fractures.10) Type IV B Type IV C Figure 12. displaced... A short arm plaster is usually adequate. unstable. Orthop. The patient is an adult or a child. M. with permission). 12. Barton’s fracture-dislocation This is an intra-articular unstable injury. J. Agee. H. undisplaced. Types 1.148 The Hand: Fundamentals of Therapy 3. et al. Closed reduction and percutaneous K-wire fixation is useful for extra-articular. Closed reduction and plaster immobilization Many fractures of the distal radius can be treated by closed reduction and plaster. Hastings. Great . It is displaced or undisplaced. Numerical classification Contemporary authors prefer to classify fractures of the distal radius numerically. Bobit Publishing Co. displaced. These classifications are determined by whether: (i) (ii) (iii) (iv) (v) The fracture is open or closed. The cast is reinforced or tightened as needed and is completed when swelling has settled. 2. It should finish just proximal to the distal palmar crease to allow unimpeded flexion of the MCP joints. The position is checked with regular X-rays. thumb. Type IVC – intra-articular. W. Symposium: Management of intra-articular fractures of the distal radius. reducible. A well-moulded plaster slab is applied initially. The carpus displaces with the articular fracture fragment. Type III Type IV A Treatment of distal radial fractures 1. the more serious the injury and Type I Type II the more uncertain the outcome. This fracture can be volar or dorsal. Some of the authors who have described classification systems include: Frykman. Closed reduction and percutaneous K-wire fixation (Fig. Type III – intra-articular. The universal classification of distal radial fractures as proposed by Cooney et al. 152 for therapy). 1990. P. It is comminuted or non-comminuted. irreducible (Fig. stable. Type IVA – intra-articular. 12. reducible. (Cooney. Oblique or comminuted fractures are unstable and likely to redisplace unless internally fixed. Melone. 71–104. Gentle wrist movements are commenced when the plaster is removed. 2 and 3. The higher the numerical rating. this is usually at 6 weeks (see p. particularly those that are low velocity. relatively stable and extraarticular.

(c) This fracture was treated with closed reduction and percutaneous K-wire fixation. (a) This 63-year-old female sustained a low velocity Colles’ fracture resulting from a fall while playing tennis. (d) Lateral view following closed reduction and percutaneous K-wire fixation. Note restoration of the distal radioulnar joint. (b) Lateral view of fracture. .10.The wrist 149 (a) (b) (c) (d) Figure 12.

The plaster is removed at 6 weeks and wrist movements are begun. (See p. 3. these may be associated with scapholunate ligament injuries which should also be repaired. 12. e.g. The wires are removed 6 to 8 weeks following removal of plaster. Palmar tilt may be more difficult to restore and often requires an extra pin or K-wire. die-punch fracture (involving the radiolunate joint) (Fig. The splint is removed every few hours so that gentle active wrist movements can be carried out. Associated soft tissue injuries. (iv) Displaced or depressed intra-articular fractures.e. (a) Figure 12. (b) Treatment of this fracture required open reduction. 12. (iii) Displaced radial styloid fractures. Open reduction and internal fixation Open reduction and internal fixation (ORIF) is achieved with plates and screws and is indicated in the following circumstances: (i) A satisfactory position has not been achieved with closed reduction. Carpal tunnel decompression is frequently required.11. cancellous bone grafting from the iliac crest and plate fixation. (ii) There is an unstable fracture pattern. i.g. Skeletal fixation via pins through the second metacarpal and distal radius allows precise. Metaphyseal bone loss should be grafted to prevent loss of reduction and non-union.11). vessels. (a) This unstable comminuted fracture of the distal radius was sustained by a 28-year-old female who fell at high speed from a snowboard. Barton’s intra-articular fracture-dislocation. firm distraction of the fracture fragments (Fig. Iliac crest bone graft is the graft of choice although various bone substitutes are available. Aftercare Open reduction and rigid internal fixation of the fracture allows early movement of the wrist which is protected initially with a plaster slab and then a thermoplastic wrist splint. The technique is excellent for restoring length and radial inclination. External fixation External fixation can be used to treat complex comminuted fractures or those with extensive soft tissue injury. nerves and tendons. (b) . 153 for greater detail.150 The Hand: Fundamentals of Therapy care is taken to avoid damage to tendons. sensory nerves and vessels when inserting the wires. Displaced or depressed articular fragments may require open reduction via a small incision.12). e.) 4. should be repaired at the same time as fracture fixation.

The arm should be elevated regularly and exercise of the proximal upper limb joints should be carried out frequently during the day. wrist posture and restriction of finger movement due to the frame. will rapidly lead to stiffness of the finger joints.13 and 12. Figure 12. new fixation devices and better surgical techniques have improved the results of these complex injuries. The patient should therefore perform active intrinsic MCP joint flexion exercises separately to extrinsic stabilized interphalangeal joint flexion exercises with the MCP joints held in neutral extension (Figs. can make finger flexion difficult.14). Active exercises usually need to be preceded by passive flexion exercises. Therapy during fixator immobilization period A thermoplastic wrist splint can be moulded around the frame of the fixator to provide volar support to the hand. To help overcome this. Nevertheless. Stabilized extrinsic interphalangeal joint flexion exercises. Active finger extension is also restricted by oedema and tethering of the extensors. Comminuted high velocity fractures of the distal radius can be difficult to treat and complication rates are high.14. Figure 12.The wrist 151 The combination of oedema. Active intrinsic MCP joint flexion. Oedema. particularly on the dorsum of the hand. External fixation was used to treat this 32-year-old man’s intra-articular comminuted distal radial fracture following a crush injury. . ‘place and hold’ exercises are Figure 12. Composite flexion is usually not possible. 12.13. is often marked and can be addressed with light application of 2-inch Coban wrap. Note the postoperative hand oedema which. if not treated promptly.12.

1. Malunion Malunion is common. hand sweating or discoloration may be an indication of CRPS. Support is then withdrawn while the patient attempts to maintain the extended position actively. The fingers and thumb are passively extended to a comfortable maximum range and held in this position for a short period. The technique facilitates accurate diagnoses of associated intra-articular injuries. triangular fibrocartilage tear and osteochondral fractures. (See ‘Therapy following cast removal after closed reduction’ for therapy management following removal of fixator. 4. . 9. Loss of grip strength Weakness inevitably follows prolonged immobilization. increased pain. i. improves. pins and needles. collar-and-cuff support is a comfortable alternative. non-union is rare. urgent carpal tunnel decompression is indicated. 1 to 2 minutes. Chronic regional pain syndrome (CRPS) This may be triggered by carpal tunnel syndrome. Complications of distal radial fractures Complications following a fracture of the distal radius are relatively common and can result from the fracture itself or as a consequence of treatment. The extensor tendons are particularly prone to tethering following complex fractures which require open reduction and internal fixation.g. radial neuritis or a tight plaster. The risk is minimized by elevation of the injured wrist. 5. particularly extension range.152 The Hand: Fundamentals of Therapy performed 1 to 2 hourly. Changes such as Therapy during immobilization period after closed reduction Postoperatively the injured limb is elevated. red. the symptoms of which may not manifest themselves for several years. Grip strength will gradually be restored as pain subsides and wrist motion. Post-traumatic arthritis This is a late complication. even after good plain X-rays and tomography. may settle after fracture reduction. 6. Elevation using pillows is preferred to the use of a sling which can contribute to shoulder stiffness. Rupture of the EPL can sometimes be difficult to distinguish from adherence of the tendon as this too can result in a flexed IP thumb joint posture. numbness or pain. e. 2. This situation is not an emergency and is overcome by tendon transfer using extensor indicis proprius. This manoeuvre is repeated until the patient is able to demonstrate active finger and thumb extension with ease. Fasciitis can be present on its own or is sometimes present with other signs and symptoms of CRPS. 3.) 5. Arthroscopy offers an excellent view of the joint and may assist with reduction and percutaneous fixation of some fractures.e. Delayed rupture of extensor pollicis longus This is more common after minimally displaced fractures and usually occurs 4 to 6 weeks after injury. careful cast application and early movement of all unsplinted joints. 8.e. i. tender bands in the palm. When the patient is ambulant. Active. particularly the shoulder in the elderly patient. Palmar fasciitis This manifests as thickened. Arthroscopy It can be difficult to assess the position of the articular surface. The tendons become adherent to one another as well as to bone. The risk of malunion is minimized by appropriate anatomical reduction via internal fixation of unstable fractures. scapholunate ligament tear. Carpal tunnel syndrome Symptoms of median nerve compression. Tendon adherence The soft tissue response associated with fractures frequently results in adherence of adjacent tendons. If symptoms persist postoperatively and are not relieved by dressing release. 7. active-assisted or passive movement of all unsplinted joints is commenced. swelling. Stiffness Stiffness can involve any joint in the upper limb.

but is more often habitual because it requires less effort. In the case of patients who are frail or those with memory problems. tendons. Active range of finger abduction readily follows improvement in the passive range. as is often the case in the older patient with degenerative arthritis. each joint is exercised individually with stabilization of the more proximal joint. oedema. When the bandage is removed. swelling. nerves or blood vessels.e. This is due not only to joint pathology but also to flexor Figure 12. fist-making) should follow individual finger flexion exercises. the patient should unfurl the fingers slowly to avoid the pain that can be associated with sudden extension following prolonged flexion. altered sensation. should not result in pain. Active movement should be preceded by passive exercises to help facilitate tendon pull-through. . The wrist will in most cases have a restricted passive/active range of movement. skin. Therapy following cast removal after closed reduction Most limb fractures. particularly of the weaker extensors which are often tethered to adjacent tissue. including closed/stable ones. e. 10 to 15 minutes) several times a day.15. cotton wool or foam can be inserted between the fingers for short periods (i. A manoeuvre that the patients find difficult. Active intrinsic MCP joint flexion exercises are added to the exercises when the patient can demonstrate a satisfactory passive range of MCP joint flexion. 3. beginning with the shoulder and working distally. 2. numbness or hand discoloration should be reported promptly as these could indicate a tight cast. flaky and/or scabby. are accompanied by a significant soft tissue response. Their recognition and treatment are important in the management of distal radial fractures. but which is effective. Where finger stiffness persists. most patients will assume a ‘hook’ grip when asked to make a fist. this results from a combination of residual oedema. Effects of fracture and prolonged immobilization A wrist that has been immobilized for 6 to 8 weeks usually presents with the following features upon cast removal (Fig. Global flexion (i. carpal tunnel syndrome or herald the onset of chronic regional pain syndrome (CRPS). This manoeuvre should provide a gentle stretch only.e. Residual oedema. a family member should be instructed in the home programme and ideally be available to supervise on a regular basis.e. the soft tissue manifestations will be more complex. perform active interphalangeal joint flexion exercises. i. ‘Place-and-hold’ manoeuvres are often easier in the initial exercise sessions. This manoeuvre should be repeated 5 to 10 times each session and continued until the patient initiates fist-making with the MCP joints rather than the IP joints. i. Active finger exercises should be performed in elevation to assist resolution of hand oedema.g. Increased pain.15): 1. is to passively flex the MCP joints to their maximum comfortable limit and while holding this position. When a fracture requires ORIF and/or is associated with injury to other tissues. Small wads of gauze.e. bony callus and soft tissue scar (fibrosis). Active and passive movements should be performed in a systematic fashion. To ensure effective flexor tendon pull-through. This is sometimes due to restrictive dorsal hand oedema.The wrist 153 Patients are encouraged to exercise for several minutes each hour when awake. 12. It is considerably thickened in appearance. The bandage is left in place for 15 to 20 minutes and the process can be repeated every few hours during the day. Larger pieces of foam are used for the thumb web and can be bandaged into position. Attention also needs to be given to the web spaces of the digits and thumb. These are made bulkier as finger abduction improves. Unless instructed. the fingers can be lightly bandaged into a ‘mitten’ by using a light crepe bandage. Particular attention is given to MCP joint flexion. bony callus and soft tissue adhesions are commonly observed following prolonged wrist immobilization. The skin is frequently dry.

A rolled towel can be placed beneath the wrist in whatever position the patient finds most comfortable. Extensor tendon lag is common. Hypersensitivity Hypersensitivity that persists beyond the first 2 weeks or which interferes with the patient’s ability to carry out their exercise programme is treated with transcutaneous electrical nerve stimulation (TENS). Warm water soaks and oil massage should be repeated several times a day as part of the home programme until the skin has returned to its pre-injury state. 5. shoulder and elbow motion is assessed. 12.16). 3. Open reduction and internal fixation frequently results in tendon adherence (also known as tethering). This is particularly appropriate for patients who find it difficult to lift their hand out of the flexed posture because of pain. While support splinting may appear to be a retrograde step following prolonged immobilization.g. This is usually achieved after 7 to 10 days. It is more comfortable in hot weather and is more economical where a series of splints is indicated. The unsupported wrist is painful for many patients. a pen. This normal postinjury wrist pain is sometimes complicated by nerve involvement. When the hand is removed from the water. the entire forearm is supported on a table.e. Serial extension splinting of the wrist The preferred material for serial wrist splinting is plaster as it gives a more contiguous fit and provides greater rigidity than thermoplastic materials. The patient is reminded to incorporate all upper limb joints into their exercise regimen. 2. begin the desensitization process. Passive manoeuvres are used judiciously. The benefits of this are skin cleansing and pain reduction. Rupture of the extensor pollicis longus tendon can be an associated complication. Serial extension splinting is instituted with these patients (Fig.154 The Hand: Fundamentals of Therapy muscle-tendon shortening after protracted immobilization in a position of wrist flexion. Supination/pronation range is often quite limited. 1 to 2 hourly. Hand bathing Following cast removal. soften the scar and assist with elimination of swelling when carried out in a distal-to-proximal direction. e. marked stiffness and/or lack of confidence. Exercise Exercise sessions during the first 2 weeks should be short but frequent. e.g. Helps resolve residual wrist oedema. Wrist support The wrist may be splinted between exercise sessions and during light daily activity. to adjacent bone or overlying skin. Before commencing wrist exercises. Residual stiffness of the interphalangeal joints is overcome by bandaging the fingers into flexion every few hours to augment the exercise programme. the author believes that progress is expedited as the patient is more likely to use the hand when pain is reduced or eliminated. and should not exacerbate pain. as suspending the hand in the air at this early stage causes discomfort to many patients. The patient should be issued with a unit for home use until hypersensitivity has resolved. Oil massage Gentle oil massage will help relax the patient. The tendons can become adherent to one another. Pain relief. an associated carpal tunnel syndrome or irritation of the radial nerve superficial branch during injury or surgery. in combination with the compressive effect of the retaining bandage. To help isolate movement at the DRUJ. the hand and forearm should be given a prolonged soak in warm soapy water. to avoid using the finger and wrist tendons as a substitute for true forearm rotation. provides good scar compression and . i. The patient is nonetheless monitored for a tendency to overuse the support. Gentle active wrist movements including flexion/extension and ulnar/radial deviation are begun with gravity eliminated at this early stage. Overcomes stiffness when used serially. this position eliminates compensatory movements of the shoulder. particularly in the older patient. Intermittent support of the wrist has the following advantages: 1. the patient should grasp a light object. Active pronation and supination exercises should be performed with the elbow joint held in 90° of flexion. 4. The close fit of the plaster.

The plaster is renewed every few days commensurate with improvement. there is a corresponding improvement in finger flexion. the results of static splinting are equal to those gained with dynamic splinting.e. Forearm rotation exercises Figure 12. Conversely. Active wrist extension is synergistic with finger flexion. The corrected position should cause only mild discomfort that usually settles quickly. In the experience of the authors. It is also important to stress to the patient that the splinting programme is complementary to their exercise and activity regimen and is not a substitute for it. As wrist extension improves. Dynamic wrist splinting Dynamic splinting of the waist is another option for overcoming stiffness.16. however.The wrist 155 tations is advisable.17. Passive and active rotation exercises need to be practised as . Where pain threshold is low or the patient is not confident enough to use the hand. Progress is influenced by the complexity of the injury and the age of the patient. it should not cause pain. The wrist can then be brought into greater degrees of wrist extension during active finger extension exercises. a soft elastic wrist support can be used as an alternative during activity (Fig. Serial plaster casting of a stiff.17). improvement in extension range over a 2 to 3 week period is often quite marked. this generally occurring after 2 to 3 months. The frequency of plaster change usually decreases after the first 2 to 3 weeks and is continued until a plateau has been reached. particularly when tendon adhesions are also present. ‘place and hold’ extension exercises are preferable to actively extending the MCP joints from their relaxed posture of slight flexion. the intermittent use of a soft wrist splint during activity can expedite progress. Tethering of the extensor pollicis longus tendon following ORIF can result in a lag at the IP joint. 20 to 30 degrees. active finger extension becomes more difficult as wrist extension improves. i. the outrigger portion of the splint can be impractical during activity. painful wrist will hasten progress by providing pain relief and increasing range of motion. The splint will also assist in active thumb extension exercises. A mallet splint can be worn intermittently to prevent a flexion deformity at this joint. To utilize the synergistic relationship between active wrist flexion and finger extension. Figure 12. early active finger/thumb extension exercises are best performed with the wrist in neutral extension or even slight flexion to take advantage of this tenodesis effect until the extensor tendons are less adherent and stronger. If silicone gel is indicated for scar management. The plaster cast should extend midlaterally on either side of the forearm and should attempt to hold the wrist in a slightly corrected position. the plaster is moulded over the covered gel. Gains at each plaster change may only be modest. Overcoming tendon adherence Silicone gel compression and scar massage are maintained until scar has softened and tendon glide has been re-established. Where there is an extensor lag at the MCP joints. This is referred to as the ‘tenodesis effect’. When a functional degree of wrist extension has been achieved. 12. assists with the resolution of residual swelling. however. Discussion with the treating surgeon regarding realistic expec- Patients often find it more difficult to regain forearm supination than pronation.

A hammer can be used as a passive weight stretch to increase forearm rotation. The patient is strongly encouraged to use the hand and upper limb in suitable home and leisure activities. Cessation of therapy programme It can be difficult to know just how long to persevere with the home splinting/exercise programme. Where possible.18. 12. rather than too much. formal exercise and splinting can be discontinued when active range of movement is equal to passive range and when there has been no increase in movement for several weeks.19. . return to the work environment is encouraged. Normal use of the hand will engender further mobility and strength. application of a dynamic rotation splint should be considered. Upgrading of treatment programme Gentle resistance is added to the programme after a month and gradually increased over the ensuing weeks. This allows unrestricted movement while providing support during activity (Fig. It is better to err on the side of caution and use too little force initially. The author has used the Colello–Abraham splint and the kit available from Smith and Nephew and has found both to be effective (Fig. As a guide. Gentle stretches into supination should be maintained for short periods often throughout the day. Holding a hammer for short periods will assist forearm supination or pronation range by utilizing the weight of the hammer’s head. Figure 12. frequently as wrist exercises. Dynamic forearm rotation splint If a satisfactory range of forearm rotation has not been achieved with passive and active exercise by the 6th week of therapy. A dynamic forearm rotation splint is indicated if the exercise programme does not yield adequate progress in forearm supination/pronation range after a period of several weeks. A minimum of 3 months is usually required to attain a functional wrist range and reasonable grip strength. Manual workers who place high demands upon their wrists can usually return to work at about 8 weeks following cast removal if good radiological and clinical union has been confirmed by the surgeon. 12. Graded weights can be used to strengthen wrist flexors and extensors and the patient’s activity programme is upgraded. Patients who are tentative about loading an unsupported wrist when they return to work are fitted with a neoprene wrist wrap. By this time the patient should have been weaned from formal therapy visits.18).19). Approval by the treating surgeon should be sought before applying this splint as there may be contraindications.20). 12.156 The Hand: Fundamentals of Therapy Figure 12. The weight can be readily adjusted by moving the hand proximally or distally along the handle (Fig. The weight of the hammer is readily adjusted by moving the hand along the handle of the hammer. The force exerted by the splint should always be gentle but prolonged.

22). however. PA view in ulnar and radial deviation (with the fist clenched). pisiform.21).24). The opposite wrist is X-rayed for comparison. The scaphoid is the only bone to cross both carpal rows. An MRI scan is very sensitive in detecting scaphoid fractures and for assessing bone vascularity. a bone scan 48 hours after injury will accurately identify occult fractures. the fracture will become visible on plain X-rays at that time.e. hamate. The appearance of the X-ray will frequently belie the seriousness of the fracture. trapezoid. Blood supply to the scaphoid Two thirds of the scaphoid surface is covered by articular cartilage through which blood vessels cannot pass.20. Clinical presentation Patients with scaphoid injuries frequently present with wrist pain and swelling after a fall.23). carpal collapse and secondary osteoarthritis of the wrist. healthy adults who are frequently athletes or manual workers. These are often high velocity injuries. A missed diagnosis and delay in treatment increases the risk of non-union. Their order of frequency is as follows: scaphoid. Ninety-seven per cent of patients with established scaphoid non-union develop wrist arthritis within 5 years. triquetrum. i. particularly in the anatomical snuffbox. there is periscaphoid tenderness. 20 per cent enters the volar aspect via the tubercle. Stress is therefore concentrated in its waist and fractures can occur with forced hyperextension. A neoprene wrist wrap allows full motion while providing firm elastic support to patients who are to return to heavy work. lunate. Scaphoid Fractures of the scaphoid represent just under 80 per cent of all carpal fractures. Treatment Conservative treatment is indicated for: . Scaphoid vascularity is therefore precarious and the bone can become ischaemic after injury. If early diagnosis is needed.The wrist 157 branch of the radial artery. 12. the wrist should be rested in a splint and reassessed at 2 weeks with repeat clinical examination and further investigations (Fig. Due to bone resorption at the fracture site. creating instability and increasing the risk of non-union. False positives occur with a 10 per cent frequency (Fig. The injury should be regarded as a fracture until proven otherwise. If there is any doubt about the diagnosis. Range of movement and grip strength are reduced. Early diagnosis and appropriate treatment are therefore important. A fracture of the scaphoid waist requires twice the force necessary to fracture the distal radius. Eighty per cent of the scaphoid’s arterial supply enters via soft tissue attachments along the dorsal ridge. expensive and not usually necessary. 45 degree oblique and lateral. A CT scan may be useful for more accurate definition of the fracture anatomy (Fig. Diagnosis Figure 12. In these patients. derived from a dorsal The fracture may not be visible on initial X-rays. 12. This statistic becomes important when one recalls that the majority of people with this injury are young. Clinically. The diagnosis of ‘wrist sprain’ should be avoided. It will also assess union and detect subtle injuries. even when appropriate views are taken. 12. capitate. inadequate treatment of a scaphoid injury may result in disabling wrist arthritis before the age of 30 (Fig. trapezium. These scans are. 12. There may be other carpal fractures and associated ligament tears. Carpal fractures Carpal fractures are common and often result from a fall on the outstretched hand.

if not impossible. This scan shows increased uptake in the scaphoid consistent with an acute fracture.23. The scaphoid fracture is difficult. A bone scan can identify occult fractures 48 hours after injury if early diagnosis is required. (a) This 19-year-old female presented with acute wrist pain after a fall. (b) The scaphoid fracture is clearly visible on repeat films taken 2 weeks later.21. A CT scan can more accurately define the fracture anatomy as in the case of this scaphoid fracture. to see on this initial X-ray. Figure 12.158 The Hand: Fundamentals of Therapy (a) (b) Figure 12.22. . Figure 12.

Reported union rates vary significantly from 60 to 90 per cent. 2.25. undisplaced fracture of the waist Stable waist fractures can be treated in a short arm cast including the thumb in a position of opposition to the index and middle fingers and the wrist in slight radial deviation and flexion (Fig. displaced waist fractures. 12. Non-union. that such motion does not occur provided Figure 12. Proximal pole fractures. e. The only acceptable result following acute fracture is solid bony union in an anatomic position. 1. Pathological fracture (Fig.25). however.The wrist 159 that the wrist and thumb are immobilized. Short arm cast used to treat a stable scaphoid waist fracture.24. Recent experimental studies have shown.26. although this is frequently longer.g. Figure 12. 5. 2. Tubercle fractures Tubercle fractures are rested in a wrist splint for 3 to 4 weeks. 4. . Pathological scaphoid fracture due to a benign enchondroma. Figure 12. Unstable. Average healing time is 6 to 12 weeks. 12. 3. Scaphoid injuries associated with carpal instability. Waist movements are then commenced. The scaphoid is the most important bone in the wrist. Use of a long arm cast has been recommended by some to eliminate scaphoid motion due to forearm rotation.26). Indications for open reduction and internal fixation 1. trans-scaphoid perilunate dislocation. Post-traumatic osteoarthritis of the wrist due to an untreated scaphoid non-union. This is best achieved by treating unstable scaphoid fractures with early internal fixation. Stable.

2. Note: Prosthetic replacement is no longer used due to the risk of silicone synovitis. Advantages of early internal fixation include: 1. Most patients regain good wrist motion within a few weeks of surgery and require little formal therapy once they are shown a home programme of active wrist exercises. 12. The best. 3. The avoidance of problems associated with prolonged immobilization. 2. Costochondral grafting (rib). Gentle active unresisted wrist exercises are then commenced. Figure 12. . swelling and tenderness over the dorso-ulnar aspect of the wrist. If required.27). Rapid functional recovery with early return to work and leisure activities. 3. The patient should refrain from heavy activities and contact sport until the fracture has united. Radial styloidectomy.e. Addition of a vascularized bone graft if indicated. hamate. 4. Finger exercises are commenced within a day of surgery. Scaphoid union following excision. 4. Triquetrum The triquetrum is the second most commonly fractured carpal bone. Debridement of the non-union to healthy bone. 3. 2. The wrist is immobilized in a soft bulky dressing or plaster splint for 7 days. Wrist denervation. surgical options include: 1. bone grafting and internal fixation are not appropriate. Assessment of bone vascularity. Clinical presentation The patient presents with pain. Triquetral fractures are often associated with other carpal injuries and usually result from a fall on the outstretched hand. in the opinion of the author. bone grafting and Herbert screw fixation.27. 6.g. Residual scar is managed with silicone gel. lunate and triquetrum). osteoporosis. capitate. muscle wasting. Salvage procedures If the scaphoid cannot be reconstructed or the wrist has already developed secondary osteoarthritis. 5. 5. joint stiffness. representing approximately 14 per cent of carpal bone fractures. There are various fixation devices. Rigid fixation using a Herbert compression screw (Fig. Total fusion. Proximal row carpectomy. is the Herbert screw. Technique Fixation is achieved via a volar approach for waist fractures and a dorsal approach for proximal pole injuries. Correction of the deformity with a corticocancellous block of iliac crest bone graft. e. Pain can often be controlled with non-operative measures such as support splinting and/or activity modification.160 The Hand: Fundamentals of Therapy Postoperative management Following surgery the arm is elevated for 24 to 48 hours. This usually takes between 6 and 12 weeks depending on the size of the graft. Increased union rate (90–95 per cent). The principles of surgical treatment are: 1. Scaphoid excision and four-corner fusion (i.

An MRI scan will also detect ischaemia early and may be used to assess the extent of the disease and the effect of treatment (Fig. 12. This will often reveal an area of cartilage damage which can be debrided arthroscopically. there is an ulna positive variance. although various vascular and mechanical predisposing factors have been implicated. in a predisposed individual. Clinical presentation Figure 12. therefore. Bone scan is useful for early detection and may be positive when plain X-ray is still normal. Ischaemia weakens the bone and allows it to collapse. collapse of the lunate and carpus is not.28.e. Kienboeck’s disease is more common in people with an ulna minus variance.29). no lunate or carpal collapse. Occasionally there are symptoms of carpal tunnel syndrome. Painful. In the later stages there may be fragmentation and secondary wrist osteoarthritis. CT or bone scans may be necessary (Fig.e. They may result from minor repeated trauma or occasionally. the last being the most common. If symptoms persist following non-operative treatment. i. Diagnosis Triquetral fractures may be small avulsions.e. Diagnosis The diagnosis is usually made on plain X-ray (Fig. Clinically there was local tenderness over the triquetrum. . un-united fracture fragments may require excision. Stage 2 – density is abnormal. The ulnar styloid is frequently longer in these patients than in the general population. The onset of symptoms is frequently triggered by trauma. 12. i. This 21-year-old man presented with ulnar-sided wrist pain due to a fall while skateboarding. the bone is sclerotic. Plain X-ray had shown a large ulnar styloid process. This will show lunate sclerosis. Treatment These injuries will often heal if the wrist is immobilized in a splint or cast for 4 to 6 weeks in comfortable extension. 12. a linear or compression fracture may be visible. The natural history of Kienboeck’s disease is unpredictable and poorly understood. arthroscopy may be indicated. They are rare otherwise.The wrist 161 Lunate Lunate fractures represent less than 2 per cent of carpal bone fractures and are usually associated with Kienboeck’s disease (avascular necrosis).28). The purpose of treatment. Classification Lichtmann’s classification for Kienboeck’s disease is widely used: Stage 1 – normal lunate density. from a single traumatic episode.30). the distal articular surface of the ulna is proximal to the distal articular surface of the radius. is to correct lunate ischaemia early in order to prevent collapse. This bone scan shows increased uptake in the triquetrum consistent with an impaction fracture. fractures through the body or impaction injuries. presents with wrist pain and stiffness often associated with swelling. The cause of this condition is unknown. The patient. Oblique X-ray views. i. Diagnosis of these fractures can be difficult. While the ischaemia is reversible. usually a young adult.

Salvage procedures If there is lunate fragmentation. 2. These conservative measures can often be used indefinitely. wrist denervation or partial or total wrist fusion.g.30. This injury is associated with sports that .29. a salvage procedure may be indicated. Age and activity level of the patient. carpal collapse or secondary arthritis. this will be unaccompanied by worsening symptoms. e. proximal row carpectomy (if capitate and radial surfaces permit). The principles of surgical treatment 1.g. Ulnar variance. 4. The presence of arthritis. 3(a) – carpal height is normal.162 The Hand: Fundamentals of Therapy Figure 12. Other techniques include dorsal capsulorrhaphy and radial wedge osteotomy. Hamate Fractures of the hook of hamate are rare and represent less than 2 per cent of carpal bone fractures. Note the ulna minus variance. Kienboeck’s disease showing advanced collapse and lunate fragmentation. 2 or 3). Reconstruct and revascularize the ischaemic lunate using a bone graft and vascular pedicle implantation (e. analgesia and activity modification. posterior interosseous artery at the wrist). MRI is more sensitive for early diagnosis of Kienboeck’s disease and can show ischaemia when a plain X-ray is normal. Unload the lunate to facilitate healing. Stage Stage Stage Stage 3 – lunate collapse is present. (i) In patients with ulna minus variance (Stage 1. 4 – osteoarthritis is present. Conservative management Mild symptoms can be managed with intermittent wrist splinting. this is achieved by a joint levelling procedure such as radial shortening or ulnar lengthening. Treatment Treatment for Kienboeck’s disease is influenced by the following factors: 1. Figure 12. midcarpal procedures such as scapho-trapezial-trapezoid (STT) fusion or capitate shortening are performed. second metacarpal artery. While there will be radiographic evidence of deterioration over time. 3(b) – carpal height is diminished. MRI scan showing Kienboeck’s disease (avascular necrosis of the lunate). 2. (ii) In patients with ulna neutral or positive variance (Stage 1. 3. more often than not. 2 or 3). The stage of the disease.

32. involve gripping a club or racket (golf. The two commonest patterns are: 1. The bone surface is smoothed off to avoid irritation of the overlying tendons and ulnar nerve. The capitate is at risk of avascular necrosis because the proximal pole is entirely intra-articular. Plain X-ray including carpal tunnel views appeared normal.31). Both closed and open techniques have been used. Active flexion of the little finger may be uncomfortable and flexor tendon attrition rupture can occur. 2. Capitate Capitate fractures represent 1 per cent of carpal bone fractures. There may be ulnar nerve symptoms due to irritation in Guyon’s canal. Perilunate dislocation (Fig. ill-defined pain over the hypothenar eminence. The fractured hook of hamate is demonstrated by this CT scan. falling from a height or a motorbike accident. revascularization procedures have been used with variable success.31. These injuries require prompt reduction. in particular. 12. the fracture may heal with rest and a trial of wrist immobilization for 4 to 6 weeks. Postoperative treatment is the same as for scaphoid fracture following ORIF. Carpal tunnel views or CT scan are required to make the diagnosis (Fig. Clinical presentation The patient presents with deep.32). e. This 28-year-old golfer presented with pain on the ulnar side of the palm. Conservative management If the diagnosis is made early.g. There is local tenderness over the hook of hamate in the palm (2 cm distal and 1 cm radial to the pisiform). taking care to avoid damage to the motor branch of Carpal dislocations Most major carpal dislocations result from a high energy hyperextension injury. Trans-scaphoid perilunate dislocation. this fracture may be missed as it is difficult to demonstrate on plain X-rays.The wrist 163 the ulnar nerve. The scaphoid and capitate are displaced dorsal to the lunate. Even when clinically suspected. tennis. scaphoid waist fractures (scaphocapitate syndrome). This bone has a poor blood supply however and risk of non-union is high. This represents an incomplete form of trans-scaphoid perilunate dislocation. Surgical management and aftercare Symptomatic non-union is treated by excision of the un-united fragment through a palmar incision. Postoperatively the wrist is immobilized for two weeks. . In the Figure 12. This 28-year-old man sustained a perilunate dislocation due to a heavy fall while playing rugby union. Figure 12. Symptoms are aggravated by gripping. A bone scan will show increased tracer uptake in the hamate. The treatment of choice is early internal fixation of one or both injuries. squash. These fractures may be associated with other carpal injuries. baseball or hockey) and is more common in athletes who grip the end of the handle in the palm. As with Kienboeck’s disease. 12. A removable splint is then used and active wrist movements are begun.

scapholunate advanced collapse deformity (the SLAC wrist). Untreated scapholunate dissociation will result in wrist osteoarthritis due to abnormal loading of articular surfaces. Scapholunate dissociation Scapholunate ligament injuries are a common cause of wrist pain and the diagnosis is frequently missed (Fig. Note also the early loss of joint space in the radioscaphoid joint. 1. Aftercare is similar to that for perilunate dislocation. The radiolunate joint is usually spared (SLAC pattern). Surgery for trans-scaphoid perilunate dislocation Open reduction is indicated for this injury and.33. If this altered motion causes symptoms. lunotriquetral dissociation.33). the scaphoid fracture should be internally fixed. . It will take most patients at least 6 months (and often longer) to return to heavy manual work. These are major carpal injuries. Bone grafting may also be required if the fracture is comminuted. Surgery for perilunate dislocations Perilunate dislocations are reduced through a combined dorsal and volar approach. the carpus is reduced and ruptured ligaments are repaired. 3. e. 3. 2. Note the increased scapholunate gap (‘Terry Thomas’ sign) and foreshortened appearance of the scaphoid giving a ‘signet ring’ appearance as a result of scaphoid flexion. The reduction is held with K-wires. scapholunate dissociation. Open reduction is therefore preferred. Bony abnormality. i. Arthritis begins here before involving the midcarpal joint. Ligament tears. This 55-year-old man has a long-standing scapholunate injury. the wrist is said to be ‘unstable’ and treatment may be indicated. at the very least. This is often associated with rheumatoid disease (ulnar translocation of the carpus) or developmental Madelung’s deformity. The final range of wrist motion is approximately 50 per cent of normal and usually takes some months to achieve. closed reduction and plaster immobilization are unreliable in maintaining anatomical alignment of the carpus. Carpal instability Increased or altered carpal motion may occur as a result of: 1.e. 12. Between the bones of the same carpal row.164 The Hand: Fundamentals of Therapy opinion of the author. Between the radius and proximal carpal row (radiocarpal instability).g. The carpal tunnel is released. Ligamentous laxity. Figure 12. Between the proximal and distal rows (midcarpal instability). Carpal instability can occur: 1. 2. Most midcarpal instabilities have involvement of both the radiocarpal and midcarpal ligaments. Postoperative management Postoperatively the wrist is immobilized in neutral for 8 weeks at which time the K-wires are removed. Gentle active wrist motion is then commenced and a removable splint is used for an additional 4 weeks.

Elbow hyperextension beyond 10 degrees. These are: PA in radial and ulnar deviation. 12. Instability may be associated with a dorsal wrist ganglion. compare with the opposite side (Fig. particularly dorsally over the scapholunate joint. Generalized ligamentous laxity is sometimes a predisposing factor. Passive extension of the little finger MCP joint beyond 90 degrees. As the wrist moves from ulnar to radial deviation. C. Churchill Livingstone. the scaphoid may resemble a signet ring. The opposite wrist should be X-rayed for comparison. the scaphoid may sublux dorsally. the lunate is extended and the scaphoid is flexed (Fig. X-ray signs that are consistent with scapholunate ligament instability include: 1. 884. Increased scapholunate gap (‘Terry Thomas’ sign). eds) p.The wrist 165 Patient presentation The patient presents with wrist pain and weakness.36). 12.) views in neutral. The Watson scaphoid shift test.e. N. R. the examiner feels the scaphoid flex. Knee hyperextension beyond 10 degrees. sometimes associated with a click or a feeling of ‘giving way’. There may or may not be a history of trauma (usually a hyperextension injury). by definition. Green. Place the examining thumb on the tubercle of the scaphoid and the index finger adjacent to the proximal pole dorsally. Carpal instabilities and dislocations. Patients with hypermobile joints are usually able to demonstrate the following: 1. are merely a static record of the wrist position at the time the picture was taken. Generalized ligamentous laxity should be looked for. is a dynamic condition. i. Foreshortened appearance of the scaphoid in the PA view due to increased scaphoid flexion. This can be felt and may be associated with a painful click. (Reproduced from Garcia-Elias. DISI pattern (dorsal intercalated segment disability). 5. . Plain X-rays are frequently normal. Hotchkiss and W. Wrist motion may be normal although there is pain on full extension. A clenched fist view may be helpful. Dorsal pressure is applied with the thumb on the scaphoid tubercle. with permission. If the S-L ligament is lax or torn. This test can be difficult to perform and may be positive in normal wrists. even if ‘motion’ or ‘stress’ views are taken. 2. 3. Pederson. Increased scapholunate angle on lateral view (greater than 60 degrees). Radiological examination A thorough history and clinical examination will usually suggest the diagnosis which is best confirmed by arthroscopy. 4. not instability. The instability grading system suggested by Herbert (1991) acknowledges the importance of clinical assessment. P.34) The Watson scaphoid shift test may be positive. 12. PA and lateral Figure 12. 2. Passive opposition of the thumb to the flexor aspect of the forearm. The Watson scaphoid shift test (Fig. Clinical assessment There is periscaphoid tenderness. Radiographs.35). Grip strength is often reduced compared with the opposite side. Forward flexion of the trunk with straight knees so that the palms of the hand rest easily on the floor. 3. The radiological features of scapholunate instability are frequently discussed but it is important to remember that instability. Always compare with the opposite side. Imaging studies frequently record fixed deformity.34. 1999. even if appropriate views are taken. M. In Green’s Operative Hand Surgery (D. 4.

Fractures and traumatic conditions of the wrist. 4. Mosby. 5. G. this demonstrates a volar intercalated segment disability (VISI). 1995. (b) When the lunate faces dorsally. capitate and metacarpal bones are collinear. (b) Note the DISI (dorsal intercalated segmental instability) pattern on the injured left side where the lunate is extended and the scaphoid is flexed. lunate.35. (a) This is the lateral view of the normal right wrist of a 22-year-old professional footballer. 3.36. Callahan. Subluxed scaphoid. Diagnostic assessment An MRI scan can demonstrate partial or complete scapholunate tears. Symptomatic wrist with no demonstrable clinical instability. D. lunate and capitate fit together like multiple Cs facing in the same direction. reducible. Dynamic ultrasound can show abnormal scapholunate motion when compared with the opposite wrist and will demonstrate an associated ganglion when present. the scapholunate angle is greater than 60 degrees (usually about 100 degrees). (c) PALMARFLEXIONINSTABILITY(VISI) Figure 12. (a) When the normal wrist is viewed in neutral extension on a lateral X-ray. This angle indicates a dorsal intercalated segment instability (DISI). W. Hunter. E. 2. K. and Kropp. Secondary osteoarthritis. E. eds) p. . (Reproduced from Frykman. (c) When the lunate faces palmarly and the scapholunate angle is less than 30 degrees.) Instability grading 1. Subluxed scaphoid. The capitate is displaced dorsally in relation to the radius. the normal scapholunate angle is from 30 to 60 degrees. 329. Mackin and A. J. Clinically subluxable scaphoid.166 The Hand: Fundamentals of Therapy Lunate 30 – 60 Scaphoid (a) NORMAL < 60 (a) (b) DORSIFLEXIONINSTABILITY(DISI) < 30 (b) Figure 12. M. Note also how the articular surfaces of the distal radius. irreducible. Note how the long axis of the distal radius. with permission. In Rehabilitation of the Hand: Surgery and Therapy (J.

37. Other surgical options include: (i) Partial wrist fusion. The ligament tear and abnormal motion are clearly visible. The reduction and repair are protected with temporary K-wire fixation (6 to 8 weeks). 12. Note the widening of the S-L interval. (b) Ligament repair and reduction of malrotation.g. non-operative treatment is appropriate. Late presentation with established arthritis Untreated scapholunate dissociation leads to arthritis resulting from the abnormal loading of articular surfaces. If the symptoms are mild or the ligament tear is partial. Gentle isometric wrist strengthening exercises are then gradually increased as comfortable. The reduction and ligament repair are protected with temporary K-wires (Fig. The wrist is immobilized in 10 to 15 degrees of extension for a period of 6 to 8 weeks. A resting wrist splint is applied and resisted activities are avoided until symptoms settle.37). Wrist flexion range will be restricted to about 60 per cent of its former range. The malrotated scaphoid and lunate bones are reduced via a dorsal approach and the ligament is repaired with transosseous sutures. As yet. When the patient returns to heavy activities and/or sport. The K-wires are then removed and active wrist movements are commenced. . e. protective strapping or a splint is applied. Conservative treatment Conservative treatment can be trialled with Grades 1 and 2. Surgical treatment and aftercare For complete ligament tears. scapho-trapezialtrapezoid (STT). Heavy physical activities are avoided for 3 months postoperatively. Arthroscopy is the most accurate way to confirm the diagnosis. (ii) Ligament reconstruction using tendon or retinacular grafts. (a) Acute scapholunate ligament disruption. no single technique has been universally successful in treating this difficult clinical problem. Cartilage wear begins in the (a) (b) Figure 12.The wrist 167 Bone scan is unreliable in diagnosing scapholunate dissociation. A removable wrist splint is applied for a further month. surgical repair is indicated. Maximum wrist motion may not be achieved for at least a year.

non-steroidal medication. pain or crepitus. i. the unrestrained lunate assumes a flexed posture and the triquetrum is distal in relation to the hamate. 3. Note should be taken of the ulnar variance as this instability may be difficult to distinguish from ulnar carpal impingement due to a long ulna. As the strap is drawn around the ulnar carpus and onto the dorsum of the hand. grasp the triquetrum and pisiform between the index finger and thumb of the opposite hand. 2. A bone scan is locally hot.e. This diagnosis can often be confused with TFCC injury or ulnocarpal impaction. the subluxed carpus is elevated (or ‘relocated’). (iii) Partial fusion (four-corner fusion. Eccentric ECU exercises. There is local tenderness over the lunotriquetral joint. Soft splint used in the early management of ulnar carpal instability. Prosser (1995) has described a programme for ulnar carpal instability that involves the following: 1. hamate. The distal ulna may be prominent.168 The Hand: Fundamentals of Therapy radioscaphoid joint and goes on to involve the midcarpus. If there has been improvement. Stabilize the lunate with one thumb. The ECU exercises are carried out 3 times a day with 10 repetitions using a 500 g weight and progressing to 1 kg in weight. injections and activity modification. . Figure 12. This correction gives most patients significant relief of pain (Fig. Conservative treatment Mild symptoms may be managed with splinting. sometimes associated with a click or clunk that accompanies active ulnar deviation of the wrist and forearm supination. Comparison should be made with the other wrist. Grip strengthening exercises are performed with the forearm in the supinated. Surgical options include: (i) Radial styloidectomy.38. Non-operative treatment involves activity modification and intermittent splinting. The splint is comprised of a snugly fitting elastic wrist brace which has a strap sewn into the ulnar aspect of the midpalmar area. The radiolunate joint is almost always spared.e. there may be a history of trauma (hyperextension). A soft splint which attempts to ‘relocate’ the subluxed carpus from its supinated position. The section of the strap which passes beneath the ulna is firm while the section over the ulnar aspect of the wrist is elasticized. (ii) Proximal row carpectomy. the splint is gradually withdrawn. Applying shear to the joint may cause abnormal motion. Lunotriquetral dissociation As with scapholunate instability. Diagnosis The ‘shear’ (or ballottement) test Stability can be assessed by ballotting the joint. 2. Patient presentation The patient presents with ulnar-sided wrist pain. Abnormal lunotriquetral motion may be confirmed by arthroscopy. Investigations Lateral X-rays may show a volar intercalated segment instability (VISI). lunate and triquetrum with excision of the scaphoid). fusion of the capitate. 12. i. Grip strengthening exercises which provide the isometric component of the programme. The splinting/exercise programme is maintained for a minimum of 6 weeks. pronated and neutral positions. Grip strength is reexamined.38). (iv) Total fusion.

no further treatment is required. If the fragment is small or there is no fracture. (Reproduced from Fernandez. Where this restraint is lacking. Volar dislocation of the Figure 12. the most reliable surgical treatment is a four-corner fusion (triquetrum. The distal radioulnar joint 1. R. There may be a supination deformity of the distal carpal row relative to the forearm bones. in the majority of cases. Anatomic reduction will usually restore the integrity of the joint and. Symptoms are often precipitated by minor trauma or repetitive activity. or levelling of the DRUJ where there is ulna minus variance. These are ligamentous avulsion injuries. this resulting in a catch-up clunk when the wrist reaches the end range of ulnar deviation. Green. Aftercare The forearm is immobilized in neutral rotation in a sugar tong splint with the wrist in slight flexion and ulnar deviation for 4 to 6 weeks. Pederson.g. Congenital ligamentous laxity is frequently associated with these conditions. 12. Hotchkiss and W. capitate and lunate). Surgery Where conservative measures prove ineffective. internal fixation with tension band wiring is carried out.39.) . P. L. Sugar tong splint used to immobilize the forearm following fractures involving the distal radioulnar joint. 1999. Fractures of the distal radius. the proximal row stays flexed for too long. hamate. the TFCC is repaired with heavy non-absorbable sutures which are passed through bone. with permission. Midcarpal instability Midcarpal instability includes a diverse group of conditions. and Palmar. The ligaments supporting these bones prevent midcarpal collapse and ensure a smooth transition of the proximal carpal row from flexion to extension as the wrist ulnar deviates. Patient presentation The patient is frequently a young female presenting with a painful click that is associated with ulnar deviation and pronation of the wrist. Churchill Livingstone. (i) The capitate-lunate instability pattern (CLIP) This appears to result from attenuation of the radiocapitate ligament which allows dorsal subluxation of the capitate during movement of the wrist into ulnar deviation. Various ligament reconstructions have been tried with limited success.39). tenodesis using a slip of ECRB). Most midcarpal instabilities involve both the radiocarpal and midcarpal joints. 3. Fractures Fractures of the distal radius often involve the distal radioulnar joint (DRUJ). the latter of these predominating. K. Ulna minus variance or an increased slope of the distal radius may also be present. Distal radial fractures are sometimes associated with fractures of the ulnar styloid. Wrist movement is sometimes restricted and grip strength is often reduced.The wrist 169 Surgery If non-operative measures fail. If the ulnar styloid fragment is large. N. In Green’s Operative Hand Surgery (D. 949. Conservative treatment Conservative management includes splinting and strengthening of extensor carpi ulnaris (see ‘Lunotriquetral dissociation’). eds) p. C. the following surgical options can be considered: soft tissue reconstruction (e. Dislocation Dislocation of the DRUJ is treated with a sugar tong splint for 6 weeks. 2. (ii) Triquetro-hamate-capitate ligament laxity This will result in a VISI deformity. A. non-steroidal medication and modification of work and leisure activities. D. Gentle active movements are then commenced (Fig. a triquetro-hamate or four-corner fusion.

Arthroscopic debridement Central TFC tears are debrided arthroscopically. Patient presentation Patients with TFC tears usually present with ulnarsided wrist pain that is often associated with a click. immobilization and anti-inflammatory medications. There may be history of a fall or twisting injury. A bone scan will show uptake on the ulnar aspect of the wrist. The unstable portion is excised and any associated articular cartilage wear on the lunate or ulnar head is also debrided. Diagnosis A plain X-ray (PA view) with the forearm in neutral rotation shows a long ulna relative to the radius. There may be cystic changes or sclerosis on the ulnar aspect of the lunate. either a single episode or repeated minor trauma. Stability of the DRUJ also depends on normal alignment of both forearm bones and integrity of the proximal radioulnar joint. PA and lateral X-ray views are taken with the forearm in neutral rotation. Instability associated with radial or ulnar shaft deformity should be treated by corrective osteotomy at the site of the deformity. Magnetic resonance imaging has an accuracy of 90 per cent in diagnosing TFC tears. Treatment for this involves arthroscopically assisted TFC repair and open reconstruction of the ECU tendon sheath if indicated. 5.41). An associated TFC tear may also be demonstrated with MRI although this investigation is rarely required (Fig. Note is taken of the ulnar variance. The condition is frequently asymptomatic.170 The Hand: Fundamentals of Therapy ulna requires immobilization with the forearm in pronation.40).g. Gentle active wrist movements within comfortable limits are then begun. triquetrum and distal ulna (ulnar carpal impingement syndrome). Diagnosis The DRUJ is assessed for instability and increased carpal supination. 12. Trauma. The entire forearm should therefore be X-rayed. The ulna positive variance may be developmental or acquired (e. . An ulna positive variance may be associated with an impaction type cystic lesion on the ulnar side of the lunate. Subluxation of the extensor carpi ulnaris tendon Peripheral TFC tears may be associated with DRUJ instability and subluxation of the ECU tendon. Ulnar carpal impingement Patient presentation The patient presents with ulnar-sided wrist pain which is aggravated by ulnar deviation. excision of radial head or premature closure of the radial epiphysis). Degenerative tears occur with an ulna positive variance and may be associated with other lesions such as articular surface wear on the lunate. Triangular fibrocartilage (TFC) injury Triangular fibrocartilage (TFC) tears may be degenerative or traumatic. 3. (Note: Patients who have an ulna positive variance often require an ulnar shortening osteotomy in addition to arthroscopic debridement. Aftercare Postoperatively the wrist is immobilized in a bulky soft dressing for 1 to 2 weeks. radial shortening due to a malunited fracture. comparison is made with the other side. Dorsal dislocation of the ulna requires immobilization of the forearm in supination. Arthroscopy has the advantage of enabling treatment at the same time. Pain is aggravated by ulnar deviation and forearm rotation.) 4. Aftercare The forearm is immobilized for 6 weeks in a sugar tong splint which holds the elbow in flexion and both the forearm and wrist in neutral. If symptoms persist. may precipitate symptoms in a susceptible individual (Fig. arthroscopy is indicated. Gentle active forearm rotation and wrist movements are begun upon removal of the splint. 12. Conservative treatment Initial treatment involves rest.

(ii) Corrective osteotomy of radial malunion.40.42(a)) Figure 12.41. Note the ulna positive variance. Surgery Surgical options include: (i) Ulnar shortening osteotomy. including the TFCC and . nonsteroidal anti-inflammatory medication and activity modification. (iii) Wafer resection of the distal ulna. (a) This 52-year-old female had ulnar carpal impingement following radial shortening due to a malunited fracture. 12. This was also treated with ulnar shortening osteotomy. MRI showing cysts within the lunate and triquetrum of a 39-year-old female with ulnar carpal impingement due to ulna positive variance. Osteoarthritis of the distal radioulnar joint (DRUJ) The patient presents with ulnar-sided wrist pain which is aggravated by forearm rotation. The soft tissues. This procedure involves subperiosteal resection of the distal end of the ulna (2 cm). The diagnosis is confirmed by plain X-ray. Surgical treatment options include: (i) The Darrach procedure (Fig. Conservative treatment Non-operative treatment involves splinting. Conservative treatment Conservative treatment involves a resting wrist splint and activity modification. (b) Correction was achieved by ulnar shortening osteotomy which restored the integrity of the DRUJ. The DRUJ is tender and irritable. 6.The wrist 171 (a) (b) Figure 12. Care is taken to protect the dorsal cutaneous branch of the ulnar nerve.

(iv) Joint replacement (Herbert ceramic ulnar head prosthesis and Swanson silicone capping) (a) Herbert ceramic ulnar head This is an uncemented prosthesis with a titanium porous coated stem and a ceramic head. Aftercare The wrist is immobilized for 2 weeks. instability of the ulnar stump can occur. a removable splint is used for a further 6 weeks. (b) Swanson silicone elastomer capping The silastic prosthesis is no longer recommended due to the risk of silicone synovitis. The pronator quadratus is brought into the pseudoarthrosis gap and sutured to the ECU sheath. Management of intra-articular fractures of the distal radius.42(b)) The distal radioulnar joint is arthrodesed and a pseudoarthrosis is created by excising a distal portion of the ulnar shaft (about 2 cm). 2–6. M. 71–104. This involves excision of the distal ulna. 12. Carpal instability. Hastings. (iii) Bower’s hemiresection interposition arthroplasty (Fig. This implant is combined with a simple soft tissue repair and restores DRUJ function more accurately than other surgical options.. Aftercare The wrist is supported in slight extension for 3 to 4 weeks. P. Proceedings of the Sydney Hospital Hand Symposium: Update on the Wrist Joint.172 The Hand: Fundamentals of Therapy (a) (b) (c) Figure 12. A removable splint is then applied and gentle active movements are commenced. The distal ulnar head is stabilized against the distal radius by a screw. .42. Aftercare The wrist is rested in an ulnar gutter for 2 weeks. The TFCC is preserved. (c) Bower’s procedure.42(c)) This procedure involves hemiresection of the articular surface of the distal ulna with an interposition ‘anchovy’ of tendon. et al. Gentle active forearm rotation and wrist movements are begun 2 weeks postoperatively. muscle or capsule to fill the vacant cavity. Orthop. This excision includes the periosteum and interosseous membrane. Early clinical results have been promising.. 12.. 21. pp. (ii) Sauve-Kapandji procedure (Fig. (a) The Darrach procedure. Aftercare The fusion is protected with a short arm cast for 4 to 6 weeks. however. (b) Sauve-Kapandji procedure. Agee. J. Contemp. Gentle active forearm and wrist movements are then begun. The ulnar head articular surface is resected and the vacant cavity is filled with tendon. W. The clinical results of this technique are unpredictable and frequently disappointing. T.. As with the Darrach procedure. Instability of the ulnar stump is a common problem. Herbert. (1990). (1991). other ligament attachments are repaired. J. Gentle active movement is then begun. References Cooney. II. H. muscle or a capsular flap.

The triangular fibrocartilage complex of the wrist: anatomy and function. 36–7. 173 Further reading Bowers. Dobyns. 292. In Green’s Operative Hand Surgery (D. 986–1032. (1993). M. Pederson. 9(2). 41–6. J. J. 13A. and Palmer. and Lipton. Hand Surg. R. Fernandez.. The Wrist. J. 139–47. J.. J. eds) pp. 70A. H. 929–85. R. Kohlhase. Fractures and traumatic conditions of the wrist. B. K. L. Herbert. N. Taleisnik. R. and Herbert. S.. Hand Ther. L. J. W. eds) pp.. M. Clinical provocative tests used in evaluating wrist pain: A descriptive study. Quality Medical Publishing. Hand Clin. J. and Ballet. Taleisnik. Nonunion of the scaphoid. Hotchkiss and W. L. Mackin and A. and Engel. Bone Joint Surg. 103–7. 865–928. 5(1). Beabout J. Hand Ther. Fractures of the distal radius. (1999) The distal radioulnar joint. Pederson. The operative treatment of intra-articular fractures of the distal radius. Weiss. Springer. D. E. Prosser. B. M. H. D. and Makhlouf. N. Splinting the wrist: mobilization and protection. 96–107. R.. Clinical examination of the wrist. W. Orthop. 1612–32. Churchill Livingstone. L. B. Ashmead. Revascularization of the proximal pole with implantation of a vascular bundle and bone grafting. J. K.. D.The wrist Prosser. J. J. 85–91. W. Hand Surg. 9(2). 12(3). Flowers. eds) pp. T. Hand Ther. Callahan. Therapist’s management of distal radial fractures. (1996). P.. 48–61. Fractures of the Distal Radius.. J. and Jupiter. K. Bone Joint Surg. In Green’s Operative Hand Surgery (D. D. Fernandez. (1999). P... Hand Ther. J. 108–10. 337–51. Staticprogressive splints. R. In Rehabilitation of the Hand: Surgery and Therapy (J. J. E. N. K. J. (1999). (1996). Aust. Fernandez. Churchill Livingstone. J. H. and Howell. Clin. . 9(2). Hand Ther. Mackin and A. Green. V. J. A Practical Approach to Management. W. M.. Physiother. Conservative management of ulnar carpal instability. Byl. (1988). Management of fractures of the distal radius: therapist’s commentary. Hand Ther. Hand Ther. T. IV. L. A. (1981). The management of carpal fractures and dislocations. (1984).. 153. (1999). (1999). In Rehabilitation of the Hand: Surgery and Therapy (J. (1999). Hand Ther. N. 6.. Green. classification and pathomechanics. P. 165–77.. Linscheid. L. Pederson. The carpus: therapist’s commentary. A. The radioulnar joints and forearm axis: Therapist’s commentary. J. Hand Ther.. J. G. Skirven. Pain on the ulnar side of the wrist. Hunter. Mosby. J. and Werner. Hotchkiss and W.. (1999). In Green’s Operative Hand Surgery (D. D. Callahan. K. Jupiter. Hand Surg.. (1992). R. Garcia-Elias. LaStayo. Schultz-Johnson. 315–36. 8(1). 12(2). (1999). J. Churchill Livingstone. 54A. 883–93. 1262–7. 51–68. (1995). (1990). B.. Hunter. K. J. J. (1995). Taleisnik. H. (1996). Palmer. Green. Feinberg. (1972). 201–11. Hand Surg.. 12(2). D. T. eds) pp. K. Functional limitation immediately after cast immobilization and closed reduction of distal radial fractures: Preliminary report. Traumatic instability of the wrist: diagnosis. 358–65. The carpus: surgeon’s perspective.. (1985). N. Frykman. (1988). F. R. 41(1). 12(2). and Schultz-Johnson. J. 657–60. R. J. (1995). and Kropp. Bone Joint Surg.. Carpal instabilities and dislocations. Watson. N. Reiss. 6A. R. (1996). Churchill Livingstone. (1995). T. Watson. W. A. Contesti. E. 9A. K. F. H. 3.. Carpal instability. Examination of the scaphoid. (1995). and Bryan. J. (1988). 10–7. eds) pp. The SLAC wrist: scapholunate advanced pattern of degenerative arthritis. G. D. J. Hotchkiss and W. P. Weinstock. The Fractured Scaphoid. 12(2). 99–102. Mosby. D. J. A.. D.

Combination of fingers and thumb. Irretrievable circulation. Single or multiple digits at various levels.1 and 13. Figure 13. The ‘radial hand’ has loss of all four fingers with the thumb remaining. Malignancy or severe infection.1. 4.2.13 Amputations – digital and partial hand Amputations involving the hand or digits can occur as a result of trauma or elective surgery for the following reasons: 1. Classification 1. 3. index and middle finger).e. Figure 13. the thumb is the primary digit for exploration. 2. representing 40 per cent of hand function. The ‘ulnar hand’ has loss of the radial three digits (thumb. The entire hand.2). radial or ulnar hemiamputation or ‘mitten’ hand involving loss of all the rays of the hand (Figs. Function and significance of thumb and digits Thumb The thumb is the most mobile and important digit of the hand. Congenital abnormality. permanently stiff and/or painful. i. 13. 3. Because the hand is an organ of touch. Thumb. 4. 2. . Together with the index and middle fingers. Digits that are dystrophic.

Ring finger The ring finger represents 10 per cent of hand function. The gripping ability of the little finger is enhanced by its greater range of motion at the MCP joint where strength is reinforced by the powerful hypothenar muscles. 1977).3. every effort is made to conserve the proximal phalanx in manual workers (Murray et al. Other requisites of normal thumb function are: 1. participates in strong digital-palmar grip. Index finger This digit represents 20 per cent of hand function and plays a vital role in precision pulp-to-pulp handling and lateral pinch. Loss of this digit results in the least functional deficit when compared to the other digits (Fig. Opposibility. pinch function will automatically be transferred to the middle finger. Loss of the ring finger allows small objects to fall through the hand. When the level of amputation approaches the PIP joint of the index finger.4.176 The Hand: Fundamentals of Therapy sensation to the thumb is as important to function as is movement. The ring finger is rarely used in precision grip. This digit provides stability and balance in delicate everyday activities such as writing and drawing. the patient’s emotional attitude toward amputation should be taken into account.. 13. Individual reaction to amputation is by no means always proportional to the extent of the loss. Because of the impact on power grip associated with total loss of the index finger. The ability of this digit to abduct widely is of great functional significance in grasping larger objects. Loss of the middle finger constitutes a greater aesthetic loss than that Figure 13. 3. Stability. Pre-injury . together with the little finger. associated with the index finger. It is the longest of the digits and its central position enables it to participate in precision as well as power grip. Wherever circumstances allow. As the level of amputation approaches the PIP joint.4). Middle finger The middle finger represents 20 per cent of hand function. Length is vital to the index finger. 2. Little finger The little finger accounts for the remaining 10 per cent of hand function. A patient who has lost the tip of a single digit may be as traumatized as another patient whose loss involves multiple digits. Psychological aspects Figure 13. In flexion. Length. pinch grip is transferred to the adjacent ring finger. The musculature of the index finger is relatively independent and this helps contribute to its strength. 13. this digit has greater strength than the index finger.3). In the case of this patient who has undergone elective ray amputation of his index finger and has a middle finger stump. as the adjacent digits tend to converge toward the residual gap. pinch grip function is automatically transferred to the middle finger (Fig. This digit.

Therapy programme Desensitization is not commenced until wound healing is complete. Self-esteem relating to body image can be seriously damaged following loss of a part.Amputations – digital and partial hand 177 personality. loss of interest in personal appearance. 13. Cold intolerance.g. psychologist or psychiatrist should be considered.5). Whatever the psychological manifestation. e. 2. These problems are a result of the injury rather than the treatment and their incidence is significant in the adult patient with loss of pulp (Conolly and Goulston. dressings can be held in place with a lightly applied layer of Coban wrap (25 mm). Financial consequences for workers with dependent families will be enormous if the individual is unable to return to pre-injury employment. Altered sensibility. or advancement flaps. Signs and symptoms of impending depression may include: loss of appetite. Choice of treatment will depend on the degree of tissue loss. Religious and cultural factors will often play an important role in the patient’s reaction. If there is any concern regarding the patient’s ability to cope with the aftermath of the injury. Management of Figure 13. attitudes and motivation will strongly influence a patient’s coping mechanism (Grant. . Potential loss of employment as a result of the injury will have major emotional and psychosocial consequences. To help reduce pulp oedema and for the provision of comfort. these injuries includes: primary closure. conversation that dwells on only negative aspects of the person’s life or withdrawal from social activities. it is important to afford it the same attention as the injured part. 1973). the presence of exposed bone and the personal preference of the treating surgeon (Fig. V-Y advancement flap following a crush injury to the tip of the index finger. Hypersensitivity. volar or local rotation. Problems associated with fingertip injuries 1. Cross-finger pedicle or thenar flaps may be indicated for the younger patient with no preexisting degenerative arthritis and in whom the development of stiffness is not considered to be a risk. referral to a social worker. Fingertip injuries Digital tip amputations are the most common type of amputation in the upper limb. V-Y. 1980). 3.5. the development of sleeping problems. splitthickness and full-thickness skin grafting.

but the condyles and any rough projections of bone are nibbled away. The hand is rested in a light plaster and kept elevated for the first few postoperative days. Neuroma formation. 3.8). and neurovascular bundles. 5.. Skin flaps of sufficient size are raised to expose the underlying bone. flexor and extensor tendons. Digital nerves are dissected and cleanly divided about 1 cm proximal to the stump. Phantom pain (Jensen et al.6). 5. Inadequate length for function. 2. If they are sutured over the stump. The wrist and digit are splinted in elevation for at least 48 h. When sufficient healing has occurred. Full range of movement is maintained at all upper limb joints. 3. Poor skin cover. the area can be covered with Opsite Flexifix. Skin is closed accurately and a non-adherent compression bandage is applied. Poor circulation. Skin is then massaged lightly with oil. 6. 13. This is accomplished by a combination of passive and active exercise and desensitization techniques. Most patients require very little formal therapy once they are shown a home programme of exercises. usually at 10 to 14 days. so that any neuroma that forms is not at the scar line. Patients are reminded to make every effort to incorporate the injured digit during activity. Opsite Flexifix can be used on its own or in conjunction with Coban wrap or a silicone-tipped fingerstall if scar management or shaping of the pulp are required (Fig. Massage pressure used can be gradually increased commensurate with the patient’s progress. Flexor and extensor tendons are cut so that they lie away from the stump. Postoperative therapy of digital amputations The aim of treatment is to regain movement and function as quickly as possible. warm water soaks are commenced to debride the area in preparation for skin management and desensitization. 4. gentle active stabilized flexion/ extension exercises are begun. This usually reduces discomfort substantially whilst still allowing full sensory input. they will interfere with the movements of the other fingers. Persisting hypersensitivity Where fingertip hypersensitivity is extreme or persistent. 7. to treat pulp oedema and to help shape the stump (Fig.6. Surgical considerations for elective digital amputation The requisites of a satisfactory stump include: 1. Stiff joints of the injured or adjacent digits. Opsite Flexifix applied to this skin-grafted middle finger tip significantly reduced hypersensitivity and allowed the patient to use the digit. Surgical technique 1. Adequate length. Early function is also encouraged (Fig. 2. It is simply replaced when it begins to lift at the edges. Possible complications 1. Three days after surgery. . Sensibility. Dystrophy. 13. 2. 6. Short gentle percussion exercises are performed on an hourly basis. 3. Figure 13. The film can be worn continuously and is reasonably water-resistant. If the amputation is through an IP joint.178 The Hand: Fundamentals of Therapy The patient is instructed in gentle passive/active interphalangeal joint exercises which should be performed frequently throughout the day. 1985). Coban wrap (25 mm) is used to hold the dressing in place. Sufficient soft tissue cover. 13.7). the articular cartilage is not removed. 4. Stump dressings should be minimal so that IP joint motion can be performed without the restriction of a too-bulky dressing.

Opsite Flexifix applied to the stump significantly alleviates hypersensitivity. 13. reduce pulp oedema and shape the stump. Coban wrap or silicone-lined fingerstalls can be used in conjunction with the Opsite for scar management and stump shaping (Fig. They are also more inclined to use the stump during activity when the film is in place (Fig. window .7.11). Patients generally find their desensitization exercises much easier to perform through the Opsite layer.10. Figure 13. The hand should be used for light self-care activities as soon as possible. Sutures are usually removed between 10 and 14 days at which time warm water soaks (containing a mild cleansing agent) are carried out several times a day. In preparation for return to work. patients are encouraged to use the hand for normal domestic and house maintenance activities.9). These will assist with wound debridement and help facilitate movement if stiffness is still a problem. Carrying light shopping bags.9. Figure 13. early function is encouraged. 13.10). Light massage with cream or oil will soften the scar and plays an important part in the desensitization process (Fig.Amputations – digital and partial hand 179 Figure 13. Coban wrap (25 mm) is used to hold the dressing in place. Following amputation. Light sponge squeezing in the water will also promote movement and help with desensitiza- tion. The area of application is highlighted. Oil or cream massage softens the scar line and is an important part of the desensitization process. assists with the desensitization process and has a positive psychological effect. Early use of the hand improves mobility. hanging out washing. 13.8. Opsite Flexifix is applied to the stump to reduce sensitivity at this early stage (Boscheinen-Morrin and Shannon. This makes desensitization exercises easier and encourages early function. 2000). Figure 13.

Transfer of a digit. this procedure is used primarily for thumb loss distal to the MCP joint. e. glabrous skin that can be reinnervated and mobile joints. The re-creation of a thumb web restored gross grasp and enabled him to complete his apprenticeship. Problems of size discrepancy (the large toe is about 20 per cent larger than the thumb) have been partly addressed with the ‘wraparound’ and ‘trimmed toe’ procedures. Second toe transfer. Toe to thumb reconstruction Complete or partial toe transfer has proved effective in reconstructing the absent or deficient thumb. Like the ‘wraparound’ technique. general health and the psychological ability to cope with sometimes numerous surgical procedures and aftercare programmes. The ‘trimmed toe’ technique – the great toe is trimmed to the dimensions of the opposite thumb. 4. 13. 5. etc. The five toe transplant options for thumb reconstruction include: 1. this procedure does provide motion. . internal fixation is used to stabilize the transferred digit.g..e. The ‘wraparound’ procedure (Morrison et al. will all help encourage normal use of the hand and entire upper limb. the thumb web.12.g. Local rearrangement of hand remnants 1.. Figure 13. Partial toe transplant.11. While toe transplantation has the disadvantage of toe loss. 3. This transfer does not provide motion. Most patients are able to resume manual work within 4 to 6 weeks after amputation. Attempting to use equipment such as vacuum cleaners or lawn mowers for short periods will help acclimatize the hand to vibration.12). a nail. occupation.13). 2. leisure pursuits and hobbies. when the metacarpal of the donor digit (e. hand dominance. Deepening of the interdigital cleft. 1980) – this procedure is suitable for thumb loss distal to the MCP joint and involves transfer of a soft tissue flap and nail from the great toe. by Z-plasty lengthening of the skin and sliding the thenar muscle attachments down the shaft of the first metacarpal (Fig. washing. Reconstruction Where replantation was not possible. index finger) is divided and transferred to the recipient stump. 2. reconstructive procedures can be considered. This 18-year-old apprentice carpenter was left with a ‘mitten’ hand following a circular saw injury at work. Reconstruction is most often used for restoration of pinch grip function. 13. Gardening activities will promote gross gripping and general fitness. Unlike the ‘wraparound’ technique. the transplanted toe mimics the structure and function of a thumb more closely than any other thumb reconstruction procedure. Silicone-lined mesh fingerstalls can be used over the Opsite film where hypersensitivity is severe or where scar management is still indicated. pollicization. Whole great toe transfer (Fig.180 The Hand: Fundamentals of Therapy Figure 13. This can involve rearrangement of hand remnants or reconstruction of the thumb itself. The patient’s suitability is assessed in terms of age. The toe has strong skeletal support. bony support is supplied by an iliac bone graft rather than the phalanges of the great toe. i.

1999). Figure 13. patient selection is therefore crucial.14.15. Immediately after surgery. its primary goal is to enhance mechanical advantage and thereby function.13. the device needs to be worn for an Figure 13. The most common types of functional hand prostheses are those which provide an opposition ‘post’ to enable gross pinch grip. By the time fitting of the device can be arranged (i.25 mm each. the cosmetic appearance of the hand is of major importance to some patients. Partial hand prostheses Where replantation or reconstruction are inappropriate or rejected by the patient. a prosthetic aid. Many will demand immediate fitting of a cosmetic digit. Although this procedure improves hand cosmesis. The lengthening process begins on the 5th postoperative day for children and the 7th postoperative day in the case of adults. Sensation in the new thumb is anticipated in approximately 4 to 6 months. especially to women. . for function and/or cosmesis. This technique was first used for elongation of the long bones in the lower limbs.e. Distraction lengthening of the metacarpals and phalanges (callotasis) Distraction lengthening is a means of restoring functional length to a hand that is skeletally deficient through trauma or congenital absence (Seitz. The extended period needs to be 2 to 3 times the duration of the lengthening period and the device is not removed until there is radiological evidence of consolidation of at least three cortices. Some patients with significant hand loss wear a cosmetic prosthesis when in public. A midshaft osteotomy is made through the metacarpals or phalanges and the distraction device is applied. Following the lengthening period. About 2–2.Amputations – digital and partial hand 181 additional period to allow complete bony consolidation. Distraction lengthening can be applied to the thumb or multiple digital rays. often weeks postinjury when the size Figure 13. This procedure requires high patient compliance.5 cm of lengthening can be obtained through remodelling of the fracture callus. The process involves four daily increments of 0. should be offered to the patient. Transfer of the great toe to the thumb two weeks after surgery.

(1984). Swanson. (1980). A. A. Further reading Barber. Clin... 40. Callahan. E. They realize that the hand appears most normal when it is being used. Hand. M.. G. Scand.. J. The hand and the psyche. 157–62. A. Hand Surg. Reconstr. B. Clin. D. Occup.14 and 13. Clin. Hand Surg. 14.. Chase.. A. R. L. J. (1981). B. K.. Early psychological aspects of severe hand injury. Fisher. (1974). L. and MacKenzie. J. (1990). J. W. M. J. (1999). (2000). 417–9. replantation and cold intolerance. N. In Green’s Operative Hand Surgery (D. Microsurg. T. J. Wilson. (1988). The social and economic consequences of finger amputations. B. 471–81. R. . and Yousif. P. (1960). The most common types of functional hand prostheses are those which provide an opposition ‘post’ against which the remaining digit(s). 43. Mackin and A. 7. 118–23. (1964). et al. Smith. et al. Transmetacarpal amputation of the index finger: a clinical assessment of hand strength and complications. (1977). Beasley. 2. P. Green. A.. 65. 44. L. 415–23. J. 48–94. Treatment of posttraumatic stress disorder after work-related hand trauma. K. 21. E. Harvey. C. Surg. 12. W. D. 575–83. Functional levels of amputation in the hand. A. Distraction lengthening in the hand and upper extremity. Management of pain following peripheral nerve injuries. J. Carman. Devine. F. H. F. Immediate and long-term phantom limb pain in amputees: incidence. 136–42. Pain. J. S. Reconstr. H. J. J. (1983). M. Hunter. Orthop. (1999). Schneider. Revision of painful distal tip amputations. O’Brien. B. C. Churchill Livingstone. J. Levels of amputation of fingers and hand: considerations for treatment. C. Churchill Livingstone. N. Acta Orthop. J. 13. J. 5.. H.. 175–8. J. and Watson H. Orthop. North Am. Gross. J. K.15). Pederson. Hand Surg. L. Problems of digital amputations: a clinical review of 260 patients and 301 amputations. C. Matloub. (1991)... B.. C. Hovgaard. and Rasmussen. In Green’s Operative Hand Surgery (D. and Shannon. 6. and Boswick. W. N. North Am. R.. Conolly.. A critical review of the results of primary finger and thumb amputations. 851–72. Sanger. Green. 347–8. Hotchkiss and W.. J. P.. 493–502. 343–59. Rehabilitation after amputations in the hand. Morrison. Backman. Neuroma formation following digital amputations. 1561–4. (1969). R. J... Grunert. Nielsen. Orthopedics. Mosby. C. Aust. (1994). 619–35... G. Digital amputation. M. Grunert. 11–5. Hotchkiss and W. P. N. clinical characteristics and relationship to preamputation limb pain. and Harvey. and Goulston. Grant. Desensitization of the traumatized hand. Z.. (1983). It has been our experience that preoccupation with the stump lessens as patients become involved in their therapy programme and begin to use their hand normally. S. Pederson. and Carter-Wilson. J. T. J. J. C. (submitted September 2000). C. and MacLeod. 177–80. (1985). Reconstruction of amputated fingertips. 44. and Graham.. R. and Hovgaard. eds) pp. D. (1973). J. Seitz. 15A. S. S. B. Hand Surg. Opsite Flexifix: an effective adjunct in the management of pain and hypersensitivity in the hand.. Angermann. 12. Aust. North Am. In Rehabilitation of the Hand (J. Backman. be they radial or ulnar. Louis. Plast. can be opposed for gross pinch grip function (Figs.182 The Hand: Fundamentals of Therapy of the stump is stable). W. Jr. eds) pp. Trauma. 5. Nystrom. A. Jensen. Wilson. 349–52. 511–5. R. (1989). Murray. S. L. Ther. M. T.. R. 267–78. K. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. W.. 23. Krebs. North Am. preoccupation with cosmesis has usually subsided and most patients no longer wish to proceed with the visit to the prosthetist. eds) pp.. Hand Surg. Clin. Surg. P. Surg.. Jebson. Amputations. H. 13B. Surg. References Boscheinen-Morrin.. P.

psoriatic arthritis. there is an Osteoarthritis Osteoarthritis is the most common form of arthritis to affect the hand. i. lubrication and vascular/bony changes all contribute to its development. Genetic predisposition is also an important factor. Osteoarthritis is not simply a failure of articular cartilage. The last three are relatively uncommon and sometimes present similarly to rheumatoid arthritis. spurs develop along the joint margin and there is associated synovitis. It mostly affects the DIP joints of the fingers and the CMC joint of the thumb and is commonly seen in postmenopausal women (Harvey and Conolly. At this stage. systemic lupus erythematosus (SLE) and scleroderma. In the early stages of the disease. the MCP joints of the index and middle fingers are characteristically affected.1). stiffness and deformity are marked. osteoarthritis (OA) and rheumatoid arthritis (RA).2). Primary idiopathic OA is a degenerative condition characterized by a disorder of hyaline cartilage. Joint loading. Where arthritis is advanced. rheumatoid arthritis. Pathogenesis The pathogenesis of OA is complex. Occasionally OA will present in an acute and severe erosive form where the symptoms of pain. This chapter will address the two more common types of arthritis. there may be contracture of the first web space with secondary hyperextension of the MCP joint. . 14. The characteristic osteophytes which become prominent as the cartilage degenerates are known as Bouchard’s nodes at the PIP joint and Heberden’s nodes at the DIP joint (Fig. The signs and symptoms of hypertrophic OA usually have a gradual onset.14 The arthritic hand Arthritic conditions which affect the hand include: osteoarthritis.e. 14. the cartilage can look reasonably healthy but histologically. a condition in which there is high absorption and deposition of iron.1. 1997) (Fig. gout. The CMC joint of the thumb is a common site for osteoarthritis in postmenopausal women. It can be primary in origin or be secondary to trauma. In haemachromatosis. Figure 14.

synthetic mitotic process occurring. 3.2. 7. Surgery: arthrodesis. Bony outgrowths (osteophytes). active. Treatment can involve one or more of the following: 1. Deformity. Improve range of movement. 8. Swelling. Sometimes symptoms are restricted to a single interphalangeal joint. Radiological changes do not necessarily correlate with the clinical picture. Principles of treatment The aims of treatment are: 1. Signs and symptoms These are usually of gradual onset and include any or all of the following: 1.5 cm) or a neoprene fingerstall can be used. 5. If a joint is immobilized for 6 to 8 weeks. implant arthroplasty. Anti-inflammatory agents are commonly prescribed. 3. the molecules that provide cartilage elasticity. Hand therapy Hand therapy for patients with OA is usually limited to postoperative procedures such as soft tissue or implant arthroplasty. Pain. gentle exercise. Alleviate pain. A lycra pressure glove can help alleviate pain and swelling. The cartilage no longer synthesizes the extracellular matrix responsible for the biomechanical functions of cartilage which include the provision of smooth bearing surfaces and load transmission. splints. compression garments. a patient may present with severe discomfort and minimal radiological evidence of degeneration. Improve functional ability. The aim of pain relief with medication is to reverse this inhibition so that muscle power can be restored. Osteoarthritis is therefore a biologically mediated phenomenon and not just a ‘wear-and-tear’ process. Stiffness. These can include oral and topical preparations. Temporary immobilization of the 1st CMC joint (trapeziometacarpal joint) with a thermoplastic hand-based thumb post can help relieve pain.184 The Hand: Fundamentals of Therapy be seen in a patient with relatively few symptoms. cartilage actually heals. Coban compression wrap (2. the thickness of the cartilage is reduced and proteoglycans. functional assessment. More commonly. Relief may be short-lived but in many cases has significant duration. corticosteroid injection. Marked joint erosion can . The presence of Heberden’s nodes is usually the first manifestation of osteoarthritis in the hands. Corticosteroid injections can give good relief from pain and inflammation. Drug therapy Joint pain produces inhibition of muscle power. in this case. Because OA is a chronic condition. osteophytes are seen at the DIP joints (Heberden’s nodes). When the joint is then mobilized. Instability. Hand therapy: heat. 6. Figure 14. Characteristic osteophytes become apparent as the cartilage degenerates. soft tissue arthroplasty. the cartilage can return to normal within three weeks. Arthritic tissue is biologically very active. Drug therapy: non-steroidal anti-inflammatory drugs. Weakness. are lost with the bone becoming osteoporotic. the patient will need to rely on self-help strategies to manage symptoms. Crepitation. Injections can be repeated. Conversely. 2. 2. The role of the therapist in conservative management is more one of teaching rather than active treatment. in other words. 4. At the PIP joint they are known as Bouchard’s nodes. 3. 2.

4. The wrist should be extended during wrapping to help accommodate maximum finger flexion. The wearing of a thermal glove in . (b) The effectiveness of flexion bandaging can be significantly augmented if gentle heat is applied. 14. particularly in colder weather (Fig.g. Where immobilization is impractical. (a) (b) Figure 14. (b) A neoprene thumb/wrist wrap provides pain-relieving support whilst allowing motion.4). immersion in warm water) is an effective precursor to active exercise.The arthritic hand 185 (a) (b) Figure 14.3). The heat-retaining properties of the material make this an ideal support during the winter. 14. The pressure of the bandage should provide a light stretch which does not produce pain. Vigorous passive exercise to individual joints is contraindicated. This support is particularly helpful where basal thumb arthritis is associated with more generalized arthritis of the wrist. (a) Gently bandaging the fingers into flexion for short periods will improve flexibility.3. a flexible neoprene support can be used (Fig. (a) Conservative management of painful basal thumb arthritis includes temporary immobilization of the joint with a thermoplastic thumb post which restricts movement of the CMC joint during activity. The bandage is kept in position for 15 to 20 minutes and the manoeuvre can be repeated several times daily. Placing the hand in warm water is simple and effective. however gentle flexion bandaging combined with heat (e.

Inability to turn door and car keys. As a rule however. making it difficult. but may also interfere with hand function. Aids to daily living are now available in most department stores. The choice between arthrodesis and arthroplasty will be dictated by the patient’s age. The patient should understand that there will be permanent loss of some thumb movement. 4. for example. 3. 2. Functional assessment Osteoarthritis involving the joints of the hand can compromise function. There should be sufficient pronation to enable pulp-to-pulp contact of the thumb tip with the fingers (Weiland. 2.5. Arthroplasty (implant or soft tissue suspension). Keys and small handles can be built up with thermoplastic materials or Handitube. tension band wiring or plate and screws.186 The Hand: Fundamentals of Therapy surgical correction. The patient will be unable to flatten the hand or adduct the first metacarpal. Excision of mucous cysts and/or osteophytes (DIP joint). Figure 14. deformity and instability can be the indication for . A terminal phalanx that is deviated may be not only ugly. Grasping cutlery or toothbrush. stability and a more predictable outcome are important. Opening jars and tins. Surgical options Surgical options for the treatment of osteoarthritis include: 1. Peeling and cutting of vegetables. Pinch and power grip can be significantly reduced. Arthrodesis Thumb carpometacarpal joint (1st CMC joint) Fusion of this joint is indicated in the younger patient requiring a painless stable thumb with powerful pinch grip. fusion). retropulsion. Where strength. 5. The first metacarpal is positioned in 40 degrees of palmar abduction and 20 degrees of radial abduction. i. pantrapezial arthritis) which is a contraindication for this procedure. Younger patients are also unlikely to have involvement of adjacent joints (i.e. For patients who place low demands on their hands and who are primarily seeking relief of pain with the preservation of some movement. have enlarged handles with a slip-resistant finish to improve grip function. Playing recreational sports most of which rely on a firm grasp. 3. A joint can be very painful for weeks at a time and then settle completely. joint fusion is the preferred procedure.e. 1997). arthroplasty may be indicated. A functional assessment commonly reveals the following difficulties: 1.e. 1999). giving little further trouble. to grip a golf club. loss of function is due to the pain which results from stress to the joint (Harvey and Conolly. Surgical treatment Transient episodes of pain are a feature of osteoarthritic joints. Arthrodesis (i. Myriad aids to daily living are now available in most department stores. activity level and general health. Commonly used utensils. Occasionally. winter is recommended for patients whose joints stiffen readily in the cold.g. e. The thumb is fused in a functional position using K-wire fixation. vegetable peelers. Stiffness of the MCP joint is also a contraindication. The main indication for surgery is pain that is persistent and does not respond to conservative measures.

The angle of fusion usually ranges from 0 to 20 degrees of flexion. A corticocancellous bone graft is taken from the iliac crest or lower radius and fixation is achieved using a compression plate which extends from the . The DIP joint is fused if there is gross instability associated with loss of function. For patients undergoing DIP joint mucous cyst excision.. The active younger patient who requires a strong. therefore. Intractable pain that does not respond to conservative measures. durable wrist. 1985). For the long and ring fingers. It is frequently seen following un-united scaphoid fractures and scapholunate instability patterns. Mostly. e. The development of Heberden’s nodes is usually the first manifestation of this disease in the hands. The patient should understand however. Although wrist arthroplasty is an option.. the angle of fusion increases slightly from the radial to the ulnar side of the hand. Gentle active movement of the MCP and PIP joints is commenced 24 to 48 hours after surgery. such as limited carpal fusions which preserve some motion. Aftercare The postoperative plaster can be replaced several days after surgery with a single finger dorsal thermoplastic splint that extends midlaterally on each side of the digit for extra protection. Consideration needs to be given to the most suitable angle and the patient should understand that this procedure is irreversible (Buck-Gramcko. consideration will need to be given to toileting needs where slight wrist flexion is required.The arthritic hand 187 Aftercare The thumb is immobilized for 6 to 8 weeks in a forearm-based splint which also immobilizes the MCP joint. Aftercare Postoperative protection for 2 to 3 weeks can be provided by small dorsal splints using a thin thermoplastic material such as Polyform Light or simply by applying one or two layers of Coban compression wrap. the bony alignment is maintained with tension band wiring. 1997). Wrist Osteoarthritis of the wrist is usually secondary to trauma. A fused DIP joint is stable. pinch grip will be affected. particularly in the younger patient. Fixation is maintained either by Herbert screws or a K-wire and cerclage wire (Harvey and Conolly.g. 2. that DIP joint fusion will affect grip function as the finger(s) cannot curl tightly around small handles and objects. removal of osteophytes can be carried out at the same time. These nodes are the result of the exostoses at the articular margins and are usually of cosmetic significance only. Distal interphalangeal joint Osteoarthritis appears to have a predilection for the DIP joints. remains the only procedure that will give a predictable result and relief of pain. The angle of fusion will depend on hand dominance and the functional requirements of the patient (Weiss et al. 1999). Where the thumb IP joint is fused. are feasible if the degenerative changes are confined to the scaphoradial region of the wrist joint (Watson and Hempton. Prior to this procedure. the angle is usually 45 degrees. It can also be the sequel to inflammatory arthritis (Hastings. 1995 and Field et al. persistent pain and gross deformity. Fusion. the wrist is fused in slight extension (15 to 20 degrees) for optimal function. Gentle active MCP and DIP joint movement is commenced within 24 to 48 hours of surgery. a lasting result cannot be guaranteed. The mobility of all unsplinted joints should be maintained. painless and more cosmetically acceptable. 1996). Functional demands dictate that this angle is slightly greater for the little finger and slightly less for the index finger PIP joint. Proximal interphalangeal joint The commonest indication for PIP joint fusion is single digit post-traumatic OA in the younger patient. This gives temporary cosmetic benefit but usually the osteophytes soon reappear. Generally. 1980). Following excision of the articular surfaces. Where the procedure is performed bilaterally. The indications for wrist fusion are: 1. picking up a small object such as a pin from a flat surface. This splint is maintained for 4 to 5 weeks or longer if bony union is incomplete. the patient’s occupation must be carefully assessed as a fused PIP joint can be a liability if the patient needs to work with the hand in a confined space. More conservative treatment.

silicone implant has been a reliable and accepted form of arthroplasty since that time. 1968 and Niebauer et al. FCR FCR Figure 14. Implant arthroplasty of the 1st CMC joint. thumb and other upper limb joints is commenced within a day of surgery. (a) Suspension arthroplasty involves excision of the trapezium and ligamentous reconstruction using a slip of the FCR tendon. permanent stabilization by capsulodesis or fusion is indicated. usually at 10 to 12 weeks.188 The Hand: Fundamentals of Therapy dorsum of the radius down to the third metacarpal. 2.. (b) The slip of tendon is used both to reinforce the ligamentous suspension and to fill the cavity left by the removal of the trapezium. Postoperative care is the same as for other silicone implants.6. introduced by Weiss. 3. Arthroplasty is the preferred option in the older patient with overall lower demands on the hand. C Sc. 1970). Aftercare Fusion of the wrist is a major procedure which often results in significant postoperative pain and swelling. Silicone elastomer implants (Swanson. 4. The MCP joint is sometimes held in slight flexion with a K-wire for a short period after surgery. Many surgeons now prefer this soft tissue procedure as it eliminates the risk Arthroplasty The use of prosthetic arthroplasty spans almost half a century. Suspension arthroplasty of 1st CMC joint (excision of trapezium) Excisional arthroplasty has a long history and gives good pain relief and a mobile thumb (Froimson. Cortical screws are used over the radius and metacarpal regions and cancellous screws help fix the carpal bones to the graft. The patient should maintain bed rest and elevation for the first 2 to 3 postoperative days. 1969) became available in the 1960s and despite problems with ‘fracturing’ and recurrence of deformity. The proximal component is composed of a chromium-cobalt alloy and the distal component is made of ultrahigh-molecular-weight polyethylene. The immediate postoperative plaster will need to be renewed at least once to accommodate changes in oedema. Suspension arthroplasty of 1st CMC joint (excision of trapezium). Implant arthroplasty of MCP joint(s). Where hyperextension of the MCP joint is a problem. The main arthroplasty procedures for both osteoarthritis and rheumatoid arthritis are: 1. the modified Swanson (a) (b) Temporary fixation of MCP joint Td. Newer implants are currently being trialled. . Implant arthroplasty of PIP joint. The wrist should not be loaded until there is radiological evidence of bony union. incorporates a flexed posture in the joint hinge which has resulted in improved MCP joint flexion range. Removal of the plate is an option but is delayed for 12 months until there is no doubt that the graft has consolidated and that fusion is complete. Linscheid has developed a new MCP surface replacement arthroplasty similar to that for the PIP joint. The wrist is protected with a removable splint and movement of the fingers. The ‘Neuflex’ silicone MCP joint prosthesis.

a painful pseudoarthrosis can develop between the metacarpal and the distal end of the scaphoid.The arthritic hand 189 Figure 14.e. A complication of this procedure is migration of the metacarpal. On removal of the splint. Normal use of the hand can usually be resumed 12 weeks after surgery (Fig. The procedure involves excision of the trapezium and ligamentous reconstruction to prevent metacarpal displacement (Fig. risk of infection with the introduction of a large foreign body or dislocation of the prosthesis. The MCP joint should be assessed for hyperextension deformity as this increases the tendency toward lateral and dorsal subluxation of the implant. Full movement of the thumb IP joint is allowed. Implant arthroplasty of the 1st CMC joint The trapezium is replaced by either a silicone elastomer implant (Swanson. 14.6). Aftercare Postoperative management is the same as for suspension arthroplasty.8. associated with silicone synovitis. the most common being flexor carpi radialis. The trapezium is replaced by either a silicone elastomer implant (Swanson) or one of the newer implants which eliminate the problem of silicone particulate synovitis. If the deformity is quite marked. A mild deformity can usually be corrected with a short period of K-wire fixation (2 to 3 weeks) following correction of the basal joint deformity. Implant arthroplasty of the PIP joint Adequate bone. The thumb IP joint is left free and should be exercised regularly throughout the day. soft tissue cover and an intact flexor/extensor mechanism are prerequisites for a successful outcome following this procedure. The wrist is held in neutral or slight extension and the thumb is held in about 50 degrees of palmar abduction and 30 degrees of MCP joint flexion. it can be corrected with fusion or proximal advancement of the volar plate. radial artery damage. Complications that can occur with this procedure include: radial neuritis or neuroma. Young active patients requiring a strong grip and engaging in heavy . the thumb and wrist are immobilized for 6 weeks with the wrist held in neutral or slight extension and the thumb in about 50 degrees of palmar abduction and 30 degrees of MCP joint flexion. A slip of the FCR tendon is used both to reinforce the ligamentous suspension and to fill the cavity left by the removal of the trapezium. Figure 14. The MCP joint may need to be stabilized by capsulodesis or arthrodesis as indicated. gentle active CMC joint movements and light unresisted activity can be commenced. Patient selection is important. This can be prevented by careful repair of the capsule and capsuloligamentous reinforcement using a strip of tendon. 14. greater than 25 degrees.8). Radial displacement of the metacarpal can result in an adducted thumb.7). 14. If there is proximal migration. The thumb and wrist are immobilized for 6 weeks. i. Aftercare Following surgery. The main complication of implant arthroplasty is dislocation.7. 1972b) or one of the newer implants which eliminate the problem of silicone particulate synovitis (Fig.

PIP joint implant arthroplasty is less suitable for this digit. 14. The most e important postoperative considerations are: 1. Aftercare The aftercare regimen will depend on whether or not there has been tendon reconstruction to correct a swan-neck or boutonni` re deformity.190 The Hand: Fundamentals of Therapy (a) Figure 14. . Following implant insertion. 2. ligaments are reattached to the proximal phalanx with appropriate tension to provide good lateral stability and alignment (Fig. Surgical technique The joint is approached from either the dorsal or volar aspect depending on whether or not flexor tendon surgery is indicated. The head of the proximal phalanx is resected and spurs are removed from the base of the middle phalanx. (b) The implant is inserted and the ligaments are reattached to the proximal phalanx with appropriate tension to provide good lateral stability and alignment. (b) manual labour are not suitable candidates for implant arthroplasty. 1999) (Fig. He was keen to restore flexion to the little finger so that he could continue his passion for playing golf.. Protective splinting of the joint for 6 weeks to avoid lateral deviation.10.e. 14. the collateral ligaments and palmar plate are released proximally.9. Implant arthroplasty of the PIP joint is occasionally indicated for the rheumatoid patient with severe swan-neck or boutonni` re deformity. The medullary canals of both phalanges are reamed in a rectangular shape to take the implant. the Figure 14. (a) The head of the proximal phalanx is resected and spurs are removed from the base of the middle phalanx. Reconstruce tion of the extensor mechanism will then be necessary. ring or little finger (Berger et al. Early commencement of gentle active and passive flexion/extension exercises. Because of lateral stresses imposed on the index finger during pinch grip activity. To expose the joint. X-ray showing implant arthroplasty of the right little finger PIP joint in a 52-year-old man who had had post-traumatic arthritis for some years with gradual loss of joint flexibility. The medullary canals of both phalanges are reamed in a rectangular shape to take the implant. i. This procedure is generally indicated for the isolated disability of the middle.9). 3 to 5 days after surgery in the absence of extensor tendon reconstruction (usually for RA).10).

12). This is applied with great caution to avoid lateral stress to the PIP joint. gentle active and passive flexion and extension exercises are commenced 3 to 5 days following surgery. exercise sessions can be performed 1 to 2 hourly with 10 to 15 repetitions. e active movement is delayed for 10 days. Exercise protocol In the absence of extensor tendon reconstruction. The dorsal finger splint will usually Figure 14. If the splint is removed for exercise. By the 2nd week. It should also include the DIP joint (Fig. . it is sometimes necessary to immobilize the DIP joint in extension using a thin thermoplastic material to avoid bulkiness during active flexion exercises. all fingers are flexed and extended together to provide lateral stability. Following correction of a boutonni` re deformity. Where there has been extensor tendon reconstruction for swan-neck or boutonni` re deformity.The arthritic hand 191 Figure 14. These can be performed within the splint by simply releasing the distal strap. Oedema control Postoperative digital swelling is usually marked and can be addressed with a single layer of 2.12. Coban should only be applied by the therapist during the treatment session rather than by relatives at home. On the 2nd or 3rd postoperative day. To maximize PIP joint motion. Following correction of a swan-neck deformity. 14. this will be evident if efforts to move the PIP joint result in hyperflexion of the MCP joints (Fig. It is important that the splint is fitted following Coban application otherwise the splint will be too tight. A liberal coating of powder over the Coban will prevent the heated thermoplastic material from adhering to the wrap during moulding.11. It may also be necessary to block the DIP joint in extension with a small dorsal splint to maximize flexion at the PIP joint (not shown). the PIP joint is e maintained in neutral extension. The patient should attempt 6 to 10 active and active-assisted repetitions every 2 to 3 hours during the 1st week of exercise. the PIP joint is maintained in 15 degrees of flexion throughout the 6-week splinting period.11). the plaster cast is replaced with a dorsal thermoplastic finger splint that holds the digit in extension (except following swan-neck correction). need to be remade after several days as swelling subsides.5 cm Coban wrap used over the dressing. 14. An MCP joint blocking splint can help concentrate flexion force at the PIP joint if the patient is overusing intrinsic muscles and ‘hyperflexing’ the MCP joints. The postoperative plaster cast is replaced by a dorsal thermoplastic finger splint 2 to 3 days after surgery. An MCP joint blocking splint is effective if the patient is overusing intrinsic musculature. The splint should hold the PIP joint in neutral extension (other than for correction of swan-neck deformity) and reach midlaterally on both sides of the digit to prevent lateral movement.

a hand-based dynamic PIP flexion splint is used intermittently throughout the day. the extensor tendon is reefed longitudinally. the patient can usually achieve this range within 2 weeks of surgery (Fig. The metacarpal and phalangeal intramedullary canals are reamed to accept the appropriately sized implant. To avoid extensor tendon lag. Flexion range is readily lost if the patient does not persevere with the exercise/splinting regimen.14. a soft tissue release of the joints is performed.13). the digit can be buddy-strapped to an adjacent finger to provide greater lateral stability. the dorsal splint is used throughout the 6-week postoperative period.9) obtained 70 degrees of active PIP joint flexion range within two weeks of surgery.14). The lateral ligaments and volar plate are usually released proximally and remain attached distally. Aim of postoperative management The aim of postoperative treatment is to gain a balance between healing and the application of controlled motion so that the newly forming capsule will permit flexion/extension while simultaneously providing lateral and rotational stability. With consistent effort. Immediate aftercare The hand is maintained in its postoperative plaster for the first 2 to 3 days in elevation. Implant arthroplasty of MCP joint(s) Implant arthroplasty of the MCP joints can be used for a single post-traumatic joint or to replace joints Figure 14.13. The programme of prolonged splinting and early movement will therefore need to be tailored to the individual patient.192 The Hand: Fundamentals of Therapy which have been destroyed by rheumatoid disease (Fig. For protection during activity in weeks 6 to 12. . all patients are advised to maintain their home programme for at least a year. Careful attention is given to the alignment of the fingers to ensure that they do not rest in ulnar deviation. Where stiffness is a problem. At all other times. Small gauze squares are placed between Figure 14. 14. The deposition and remodelling of collagen around the implant will vary from patient to patient. Some patients have a greater propensity to stiffness. He was fitted with a gentle dynamic hand-based flexion splint in the 3rd postoperative week when some tightening over the dorsum of the joint was becoming evident. The patient was advised to maintain passive and active flexion exercises and intermittent flexion splinting for at least a year after surgery. however. The head of each metacarpal is resected. This is achieved either with pillows or a non-constrictive sling. Light activity is begun following splint removal. Anticipated flexion range Flexion range of the PIP joint following arthroplasty is in the vicinity of 70 degrees. Implant arthroplasty of the MCP joint(s) can be used for a single post-traumatic joint (such as in the case of this 48-year-old man who sustained a crush injury) or to replace joints which have been destroyed by rheumatoid disease. Surgical technique Through a dorsal transverse incision. 14. The 52-year-old patient (see Figure 14.

If attempts at active MCP joint flexion result in a ‘hook’ grip from overuse of the extrinsic flexors. The slings should place the digits in a slightly radial orientation to help prevent recurrence of ulnar drift. . Full flexion of the index and middle fingers is less critical to grip function. Particular attention is given to the flexion range of the ring and little fingers.16). A dorsal dynamic extension outrigger is fitted 3 to 4 days postoperatively. It is a systemic disease and is really an inflammatory synovitis rather than an arthritis (Ferlic et al.The arthritic hand 193 the digits to help maintain a slightly radial position. removing the slings of the ulnar two fingers during exercises may be necessary to gain a greater flexion range. Finger slings are worn on the proximal phalanges and hold the MCP joints in neutral extension with gentle elastic band traction. Exercise protocol Active MCP flexion exercises. Rheumatoid disease is the most common of the connective tissue disorders. global flexion can be attempted. The fingers are moved in a painfree range as a single unit to maintain correct alignment. The exercises are practised 5 to 10 times every 2 to 3 hours. 14. PIP and DIP joints. A resting splint is used for greater comfort at night. If this cannot be achieved with relative ease. It is therefore important that the patient is seen regularly during these early weeks so that progress can be monitored. active and active assisted MCP joint flexion and extension exercises are commenced. When this difficulty has been overcome.15). Finger slings are placed on the proximal phalanges and hold the MCP joints in neutral extension with gentle elastic band traction (Fig. Movement not gained prior to this time will be difficult to achieve. Lightly resisted activity is commenced at 8 weeks and gradually upgraded.. Some surgeons prefer to maintain the outrigger and night splint for a 12-week period. simultaneous flexion of the MCP. with 5 to 10 repetitions. Cold packs can be used to help manage oedema and to alleviate pain. When the patient has achieved a good range of intrinsic MCP joint flexion range. Sutures are removed at 2 weeks and gentle oil massage to the scar is commenced.e. 14. Intermittent dynamic flexion splinting may need to be maintained for some months following surgery.15. The splint holds the wrist in 25 to 30 degrees of extension. global (or composite) flexion is attempted. The patient is encouraged to aim for 45 to 60 degrees of flexion at the index/middle fingers and 70 degrees of flexion at the ring/little fingers. The tension of these bands is monitored daily for signs of fatigue and adjustments are made as necessary. are performed hourly against the gentle tension of the rubber bands which will then return the joints to neutral extension. it will be necessary to immobilize the interphalangeal joints in extension with small finger splints so that the flexion force can be transmitted through the MCP joints.. The reconstructed joint will begin to ‘tighten’ during the 2nd postoperative week. On the 2nd postoperative day. Dynamic extension outrigger On the 3rd or 4th postoperative day when oedema has subsided and some wound healing has occurred. A layer of Opsite Flexifix film or Hypafix will help flatten the scar as well as prevent irritation by the splint. Dynamic MCP joint flexion splinting A dynamic MCP joint flexion splint can be used intermittently throughout the day from the 3rd week onward to help overcome joint tightness. the hand is fitted with a dorsal dynamic extension splint which is used during the day. The extension outrigger and night splint are worn at all other times until the 6th postoperative week when the hand can be used for light daily activity. Rheumatoid arthritis Figure 14. Decisions on just how long the splinting/ exercise regimen should be maintained are made on a case by case basis (Fig. Gentle shoulder and elbow exercises are carried out regularly throughout the day. i. 1983).

1971). usually involving numerous joints and other tissues or organs. In those patients not responding well to medication and where pain. The inflammatory synovium forms a pannus which grows over and infiltrates cartilage. e. Joint subluxation and/or dislocation is seen together with synovitis. Each may be effective for a particular patient. stiffness and deformity. the deformity can be passively corrected. .194 The Hand: Fundamentals of Therapy Principles and types of management Management of the rheumatoid patient requires a multidisciplinary approach involving several or all of the following health professionals: family physician. tendons and ligaments and can result in: 1. evaluation and treatment are an ongoing process. A dynamic MCP joint flexion splint is used intermittently after the 3rd postoperative week when tightness over the dorsum of the joint(s) usually becomes apparent. stiffness and deformity are troublesome. tendon glide may be impaired and crepitant. no joint destruction. rheumatologist. 2. the timing of which will vary from patient to patient: 1. Synovitis of joint and tendon mechanisms resulting in pain and swelling. The pathogenesis of RA is thought to be an immunological response occurring in the synovial tissues. Because rheumatoid arthritis is not a static condition. antimalarials. 4. 5. To teach the patient joint protection techniques and provide information about the disease. These factors combine to cause pain. 4. Stretching of the joint capsule. Rheumatoid disease can also be associated with skin and pulmonary nodules. To maintain and/or improve muscle strength with isometric exercise. inflamed joints. The psychological and social implications of this chronic and disabling condition also need to be considered in the overall assessment. However.g. Therapy Many patients now diagnosed with rheumatoid disease are well controlled with the newer drug regimens and may have little need of therapy intervention. 3. Apart from providing support to painful. Involvement of hand structures cannot be viewed in isolation because the disabling effects of this disease are manifold. Disruption of ligamentous insertions. Drugs used in treatment include salicylates. splints are sometimes used to place the wrist. 3. 2. Stages of rheumatoid disease Rheumatoid arthritis can be divided into four clinical phases. Impaired tendon glide. therapists. every drug can have significant side effects and patient response and dosage must be carefully monitored and regulated. the goals of therapy are: 1. surgeon. 5. purpura. cytotoxics (methotrexate) and immunosuppressants. gold. The deformity has become fixed. 4. Figure 14. Joint destruction is evident. the carpal tunnel. steroids. 3.16. To maintain and/or increase joint mobility with gentle active and active assisted movements performed in a pain-free range. vasculitis and intrinsic muscle fibrosis. Erosion of cartilage and subchondral bone. To provide support to painful joints with night and intermittent day splinting. however. Medical management Drug therapy is the first line of defence used to control the disease process. no deformity is seen at this early stage. Nerve compression when present in closed compartments. social worker and orthotist (Sones. 2. To determine functional problems and recommend aids to daily living and modifications to the patient’s home-work-leisure environment..

This collapse deformity is thought to be responsible for the recurrence of ulnar drift of the fingers following MCP joint arthroplasty (Fig. that splints do not reverse deformities and probably do little to prevent further deterioration of an already existing deformity. It involves the radiocarpal ligaments. Green. Volar subluxation/dislocation of the MCP joints and ulnar drift of the fingers The finger MCP joints are particularly vulnerable to the deforming forces of rheumatoid disease because they allow motion in two planes and are therefore less stable (Fig. e. The ECU tendon subluxes volarly.18. Deformities of the rheumatoid hand Dorsal subluxation of the ulnar head This is characterized by a prominent ulnar head. M. Pederson. 3. Hotchkiss and W.) of the MCP joints. Ulnar translocation of the carpus This deformity also involves the radiocarpal ligaments which have undergone the attritional effects of chronic synovitis. It should be noted. The distal ulna dislocates dorsally.g. Wrist synovitis generally begins in the ulnar carpus. Churchill Livingstone. C. 873. Ulnar translocation of the carpus involves the radiocarpal ligaments which have undergone the attritional effects of chronic synovitis.17). Collapse deformity of the wrist is characterized by radial deviation of the metacarpals and concomitant ulnar deviation at the MCP joints. Carpal instabilities and dislocations. . Note the erosion at the MCP joints. 14. stretching the ulnar carpal ligaments and the triangular fibrocartilaginous complex (TFCC). 14. (Reproduced from Garcia-Elias. with permission. The consequences of this are three-fold and are known as the ‘caput ulna syndrome’: 1. P.19). R. The subsequent loss of carpal height results in an imbalance in the extensor tendon mechanism.17. the destruction of which results in scapholunate dissociation and rotational instability of the scaphoid (volarly) and the lunate (dorsally). N. eds) p.The arthritic hand 195 thumb or digits in a more functional position. These factors result in painful and restricted forearm rotation. 14. loss of wrist extension and a radially deviated wrist from the unopposed ECRL and ECRB muscles. Attrition ruptures of the ulnar extensor tendons are commonly associated with this syndrome which is seen in about a third of patients with rheumatoid disease. however.18). The carpus translocates ulnarly due to ligament insufficiency. The aetiology of MCP joint deformity involves wrist pathology. This resultant ligament insufficiency can cause the carpus to slide down the radius and translocate ulnarly (Fig. The carpus supinates in relation to the hand. In Green’s Operative Hand Surgery (D. imbalance of Figure 14. Collapse deformity of the wrist This deformity is characterized by radial deviation of the metacarpals and concomitant ulnar deviation Figure 14. 2. tendon forces. a soft splint to correct ulnar drift of the fingers will sometimes enhance pinch grip function.

14. intrinsic musculature and the effects of gravity and pinch grip force. hyperextension of the PIP joints readily ensues.196 The Hand: Fundamentals of Therapy Figure 14. lengthened and may rupture. The extensor mechanism is stretched as a result of chronic synovitis causing the tendons to slip ulnarly. the thumb can develop a boutonni` re or swan-neck deformity. hyperextension at this joint readily ensues. the primary problem lies with synovitis of the MCP joint. the deformity becomes fixed. Ulnar drift of the fingers is a common deformity in rheumatoid disease. With the MCP joints locked into a flexed position. the intrinsic muscles are able to exert a greater force through the central extensor tendon and if the PIP joint volar capsule and palmar plate are stretched as a result of the disease process. Hyperextension of the MCP joints results from compensatory efforts to extend the PIP joint. In the early stages. further accentuating hyperextension of the PIP joint with reciprocal flexion at the DIP joint. As the joint capsule gradually contracts. this deformity is passively This deformity is characterized by PIP joint hyperextension and DIP joint flexion. With the MCP joints in this flexed position. Thumb Like the fingers. In the case of the latter. the primary . Because the PIP joint capsule and volar plate are already stretched from the disease process. As the deformity develops. the lateral bands slip dorsally. There is secondary shortening of the oblique retinacular ligament which results in DIP joint hyperextension and limited active flexion of this joint.19. Where there is elongation or rupture of the distal extensor tendon. the intrinsic muscles exert a greater force through the central extensor tendon. The extension force of the tendon is therefore diminished. the swan-neck deformity can be secondary to a mallet-type deformity. Due to proliferative synovitis. the central extensor tendon is weakened. flexing rather than extending it. difficulty in initiating finger flexion with the extrinsic flexors may result in excessive flexion effort being transmitted through the MCP joints via the intrinsic musculature. Swan-neck deformity Figure 14. Boutonniere (button-hole) deformity ` This deformity is characterized by flexion of the PIP joint and hyperextension of the DIP and MCP joints.20. correctable. Where there is flexor tendon synovitis. In the case of the e former. The lateral bands fall below the axis of the joint. The deformity can originate at either the PIP or DIP joint (Fig. Flexor tendon forces can further stretch already compromised volar capsular and ligamentous structures. Swan-neck deformity is characterized by PIP joint hyperextension and DIP joint flexion.20).

Wrist procedures that relieve pain and/or correct deformity (i. Types of surgical procedures Surgical management The presence of deformity is not necessarily an indication for surgical intervention. 5. 1974). e. Volarly. Joint replacement (arthroplasty). Tenosynovectomy/joint synovectomy. Joint fusion (arthrodesis). resection of distal ulnar head. If the patient is seen in the early stages of the disease. The intrinsic musculature of the thumb can become contracted. The tendons of the thumb. the shoulder and elbow. corticosteroids.e. Tendon involvement may precede joint involvement by months. 3.g. the extensor tendons are surrounded by synovial sheaths only at the wrist. i. Alleviate pain. or to vasculitis and poor tissue nutrition.e. 2. Where other upper limb joints are . The patient must also understand that surgery cannot restore the hand to its pre-diseased state and that weakness remains a feature of the condition. Tenosynovectomy is indicated if drug therapy has not succeeded in controlling proliferative synovitis after 3 to 6 months of treatment.e. The type of procedure performed will be influenced by the stage of the patient’s disease. the effectiveness of drug treatment in managing progress of the disease. The rheumatoid hand can have surprisingly good function in the presence of marked deformity. 6. in the palm and in the fingers.21). FPL. partial or total wrist fusion. Tenosynovectomy/joint synovectomy Because rheumatoid arthritis is a disease of the synovium. Reconstruction of the hand will be of little use if the patient cannot place the limb for effective function.g. 4. partial or total wrist fusion) usually precede surgery of the MCP and PIP joints. It must be borne in mind that surgery can worsen function. Aims of surgery 1. can be affected by attrition rupture or displacement. Soft tissue reconstruction/intrinsic release. 14. Attrition rupture most commonly involves the EPL tendon. psychosocial and economic situation. 1. 3. Both deformities are exacerbated by forces generated during pinch grip activity. (b) restriction of tendon glide and (c) attrition rupture which occurs when the synovial tissue eventually infiltrates the tendon substance. Restricted tendon glide will result in joint stiffness and secondary deformity (Fig. Reconstructive procedures that have a more certain outcome. At the time of prophylactic tenosynovectomy. 4. 50 to 70 per cent of patients with tenosynovitis are found to have infiltration of the tendon (Millender et al. surgical procedures that may have a preventative role are carried out first. Tendon repair or transfer. swelling in this area is more apparent than when present in the palm. the thumb is aligned in a position of function relative to the reconstructed fingers. Wound healing following any surgical procedure may be impaired due to the side effects of prescribed drugs. should be performed before more complex procedures such as joint replacement and soft tissue reconstruction. Dorsally. involved.The arthritic hand 197 problem occurs at the CMC joint. Trigger finger is common due to synovial hypertrophy within the flexor tendon sheaths. EPL. general health and functional requirements. surgery should be considered in the context of the patient’s medical. the age of the patient. Enhance function. EPB and APL. Tenosynovitis can cause the following: (a) pain. Hypertrophic synovium is dissected away from the tendons with small scissors or a rongeur. Also. e. Slow the progress of the disease. 2. Frayed extensor tendons are repaired where feasible or sutured to an adjacent extensor tendon. the sheaths surrounding many of the wrist and hand tendons can be involved. Improve cosmesis. These will include tenosynovectomy and joint synovectomy. Because dorsal skin is thinner. these may need to be addressed prior to surgery of the hand. Consultation with relevant family members and other health professionals involved in the patient’s care is important in determining the best possible outcome. Finally. 1. tendons glide in synovial-lined sheaths at the wrist. Compression of the median nerve is a potential complication. i. Resection of the distal end of the ulna (Darrach procedure)..

These joints are splinted in the extended position until the patient can demonstrate active MCP joint extension.22. The most common flexor tendon to rupture is flexor pollicis longus. it is hoped that active finger flexion will equal passive flexion range. Following attrition rupture. FDS to the ring finger can be utilized.24). If not. Aftercare The wrist is supported for 2 weeks. Incision sites for flexor tenosynovectomy. flexor synovectomy is carried out together with carpal tunnel decompression (Vainio.198 The Hand: Fundamentals of Therapy Figure 14. e. Flexor tendon nodules are excised. 14.g.. 14. Mostly the tendon stump is sutured to the adjacent extensor tendon (Fig. Single tendon rupture is most common in the little finger. end-to-end repair is rarely possible. 1999) (Fig. Figure 14. thumb extension can be restored with an extensor indicis transfer (Smith. Tendon involvement may precede joint involvement by many months. In the case of multiple extensor tendon ruptures there is usually an available extensor motor available for tendon transfer. At the time of repair.23). dorsal tenosynovectomy and ulnar head excision may be carried out. In the case of EPL rupture. Following flexor tendon synovectomy. 1987). emphasis is placed on individual stabilized IP joint flexion and extension exercises. the MCP joints should be maintained in extension between exercise sessions to prevent extensor lag. Gentle active finger movement is commenced the day after surgery. Following dorsal tenosynovectomy. Proliferative flexor tendon synovitis can result in pain on active flexion and restrict tendon glide as in the right hand of this patient. 1957) and the removal of bony spicules. Extensor tendon attrition rupture occurs most frequently at the distal end of the ulna and at Lister’s tubercle (EPL). over the scaphoid to prevent FPL rupture. Tendon transfer is contraindicated in the presence of MCP joint deformity unless this is first corrected with implant arthroplasty. Tendon repair or transfer Volarly. Finger extension exercises should be performed extrinsically.21. This rupture results from attrition caused by a scaphoid osteophyte and is . Ruptured extensor tendons do not always result in loss of function and can at times be difficult to distinguish from pre-existing joint deformity (Feldon et al. 2. The wrist joint is assessed and synovectomy is performed if there is evidence of joint involvement. This is achieved by holding the interphalangeal joints in flexion where possible (using Micropore or Coban wrap) during active extension of the MCP joints. Following surgery.

however. This is important in stabilizing the distal ulna and to correct carpal supination. has shown itself to be an effective procedure that has withstood the test of time. otherwise the forearm is maintained in supination in the sugar tong splint for 3 weeks. Single tendon rupture is most common in the little finger. Following attrition rupture of the EDC tendons to the ulnar three fingers.24. 1969). the wrist and fingers are splinted in extension with the forearm in supination in a sugar tong splint. 4. This problem usually settles. 3. until active finger extension can be demonstrated by the patient. the tendon can rarely be repaired. Where satisfactory soft tissue reconstruction was able to be achieved. Extensor tendon rupture can be difficult to distinguish from pre-existing joint deformity. The tendon of extensor indicis proprius (EIP) is transferred to extensor digitorum communis of the ring and little fingers. the wrist will need to be . Aftercare Postoperatively. Attrition rupture of the extensor tendons occurs most frequently at the distal end of the ulna and at Lister’s tubercle (EPL). Following resection (2 cm or less).The arthritic hand 199 Figure 14. The stump of the extensor digitorum communis of the middle (long) finger is sutured side-to-side to the index finger EDC. Gentle active finger movements are begun the day after surgery with the fingers splinted in extension between exercise sessions Figure 14. the dorsal edge of the distal ulna is bevelled and covered with a soft tissue layer to prevent tendon attrition. it is repositioned dorsal to the axis of wrist flexion and retained by a ‘sling’ made from the extensor retinaculum. EDC EIP referred to as Mannerfelt’s lesion (Mannerfelt and Norman.23. Where MCP joint deformity is associated with marked wrist involvement. Arthroplasty of the MCP joints. Fusion of the thumb IP joint in a functional position may be indicated. Where the ECU tendon has displaced volarly. Those patients using a short arm splint can commence gentle active forearm rotation as soon as postoperative pain and swelling have subsided. Forearm rotation can therefore be painful and accompanied by a ‘click’. the ulna can have a tendency to sublux. Because of tendon fraying and retraction. Soft tissue reconstruction is carried out if the triangular fibrocartilage has been destroyed. the following salvage procedure can be performed in the absence of MCP joint deformity. Resection of the distal end of the ulna (Darrach procedure) Excision of the distal ulna can be carried out on its own if symptoms are confined to the distal radioulnar joint or be combined with radiocarpal synovectomy in the case of early erosive changes. a short arm splint is used after the first few days. The distal ulna can be stabilized using a flap of volar capsule or a strip of ECU tendon. Joint replacement (arthroplasty) Wrist arthroplasty has shown inconsistent results and the indications for its use are limited. For several months following surgery.

335–57. In The Hand (R. the PIP joint is e corrected first. Figure 14. Tubiana. In Green’s Operative Hand Surgery (D. arthrodesis can relieve pain and provide stability as in the case of this wrist. Orthop. Green. Beckenbaugh. M. Terrono. L. (1983). and Linscheid.. Pederson. Arthroplasty of the PIP joint is performed less frequently than MCP arthroplasty in the rheumatoid hand and the two procedures are not carried out in the same digit.. Total wrist fusion: A functional assessment. 147–91. Hotchkiss and W. (1997). Because of poor bone stock. I. Churchill Livingstone. R. eds) pp. A. Medical considerations and management of rheumatoid arthritis. 662–6.) pp.. (1985). 703–6. C. N.. To improve forearm rotation. In Atlas of Hand Surgery (W. Harvey. It is anticipated that patients will retain 25 to 50 per cent of motion following this procedure. Field. prolonged immobilization may be necessary using both internal and external splints. Feldon. Churchill Livingstone. this should precede joint replacement by several months. and Conolly. extensor tenotomy. Hotchkiss and W. Saunders. D. Buck-Gramcko. R. Conolly. P. 1651–739. Hand Surg. A. J.. MCP joint arthroplasty is carried out at the same time as correction for swan-neck deformity. 70. B. ed. ed.. Churchill Livingstone. F.. W. Compression arthrodesis of joints in the hand. J. (See section on ‘Osteoarthritis’ for aftercare following implant arthoplasty. 429–33. H. P. Synovium is concentrated in areas where ligaments are plentiful. and Clayton. L. B. (1996). They include: reconstruction of the extensor mechanism. flexor tendon tenodesis. R. Smyth. Rheumatoid arthritis and other connective tissue diseases. 8. B. recon- struction of the oblique retinacular ligament and either skin release or dermadesis. replacement of the ulnar head was also carried out. Osteoarthritis. 6. C. References Berger. In the case of boutonni` re deformity. Radiocarpal fusion is indicated for patients with established ulnar carpal translocation. J. These procedures are frequently carried out in conjunction with either implant arthroplasty and/or joint fusion. Midcarpal fusion is often unnecessary as this joint is usually spared in the disease process due to the paucity of ligaments. Arthroplasty in the hand and wrist. L. 191–9. Where there has been extensive joint disruption. R. Herbert. and Prosser. Soft tissue reconstruction/intrinsic release Procedures for soft tissue reconstruction and release will vary according to the type of deformity and whether or not the deformity is flexible or fixed. Partial or limited wrist fusion is indicated for patients with collapse deformity. . Mobility of all joints proximal and distal to the fusion should be maintained. Pederson. A. Tendon arthroplasty of the trapeziometacarpal joint. (1999). Joint fusion (arthrodesis) Joint fusion is used to stabilize a dislocated or painful joint as an alternative to implant arthroplasty. P. Green. R.200 The Hand: Fundamentals of Therapy addressed first. (1970). C. Fusion of individual joints in the fingers and thumb is often performed in association with either implant arthroplasty and/or soft tissue reconstruction. The fusion may be supplemented with an autogenous bone graft and requires approximately 10 weeks of immobilization in a short arm cast. J. Nalebuff. Hand Surg. lateral band mobilization. and Millender. J. J.) 5. C. This procedure involves fusion of the scaphoid and lunate bones to the radius. W. Ferlic. Where finger deformity involves all three joints. D.) pp.25. eds) pp. D. N. E. In Green’s Operative Hand Surgery (D. Clin. T. Froimson. If tenosynovectomy is required. R. L.. (1999). A. 21B.

The arthritic hand Hastings II, H. (1999). Wrist (radiocarpal) arthrodesis. In Green’s Operative Hand Surgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) pp. 131–46, Churchill Livingstone. Mannerfelt, L. G. and Norman, O. (1969). Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel. A clinical and radiological study. J. Bone Joint Surg., 51B, 270–7. Millender, L. H., Nalebuff, E. A., Albin, R., et al. (1974). Dorsal tenosynovectomy and tendon transfer in the rheumatoid hand. J. Bone Joint Surg., 56A, 601–10. Smith, R. J. (1987). Tendon transfers for rheumatoid arthritis. In Tendon Transfers of the Hand and Forearm (R. J. Smith, ed.) pp. 215–43, Little, Brown. Sones, D. A. (1971). The medical management of rheumatoid arthritis and the relationship between the rheumatologist and the orthopaedic surgeon. Othop. Clin. North Am., 2, 613–21. Swanson, A. B. (1968). Silicone rubber implants for replacement of arthritic or destroyed jointsin the hand. Surg. Clin. North Am., 48, 1113–27. Swanson. A. B. (1972b). Disabling arthritis at the base of the thumb. Treatment by resection of the trapezium and flexible (silicone) implant arthroplasty. J. Bone Joint Surg., 54A, 456–71. Vainio, K. (1957). Carpal tunnel syndrome caused by tenosynovitis. Acta Orthop. Scand., 4, 22–7. Watson, H. K. and Hempton, R. E. (1980). Limited wrist arthrodesis. Part 1: The triscaphoid joint. J. Hand Surg., 5, 320–7. Weiland, A. J. (1999). Small joint arthrodesis. In Green’s Operative Hand Surgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) pp. 95–107, Churchill Livingstone. Weiss, A. P. C., Wiedeman, G., Quenzer, D., Hanington, K. R., Hastings, H. and Strickland, J. W. (1995). Upper extremity function after wrist arthrodesis. J. Hand Surg., 20A, 813–7.

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Further reading
Bass, R. L., Stern, P. J. and Nairus, J. G. (1996). High implant fracture incidence with Sutter silicone metacarpophalangeal joint arthroplasty. J. Hand Surg., 21A, 813–8. Brattstrom, M. (1987). Joint Protection and Rehabilitation in Chronic Rheumatic Disorders. Aspen Publishers. Brumfield, R. Jr., Kuschner, S. H. and Gellman, H. (1990). Results of dorsal wrist synovectomies in the rheumatoid hand. J. Hand Surg., 15, 733. Clawson, M. C. and Stern, P. J. (1991). The distal radio-ulnar joint complex in rheumatoid arthritis: an overview. Hand Clin. 7, 373. Conolly, W. B. (1997). The rheumatoid hand. In Atlas of Hand Surgery (W. B. Conolly, ed.) pp. 359–84, Churchill Livingstone.

Linscheid, R. L. and Beckenbaugh, R. D. (1991). Arthroplasty of the metacarpophalangeal joint. In Joint Replacement Arthroplasty (B. F. Morrey, ed.) pp. 159–72, Churchill Livingstone. Linscheid, R. L., Murray, P. M., Vidal, M. A. and Beckenbaugh, R. D. (1997). Development of a surface replacement arthroplasty for proximal interphalangeal joints. J. Hand Surg., 22A, 286–98. Madden, J. W., Arem, A. and DeGore, G. (1977). A rational postoperative management program for metacarpophalangeal implant arthroplasty. J. Hand Surg., 2(5), 358. Melone, C. P. Jr. and Taras, J. S. (1991). Distal ulna resection, extensor carpi ulnaris tenodesis, and dorsal synovectomy for the rheumatoid wrist. Hand Clin. 7, 335–43. Nalebuff, E. A. (1969). Hand surgery and the rheumatoid patient. Surg. Clin. North Am., 49, 787–97. Niebauer, J. J., Shaw, J. L. and Doren, W. W. (1969). Siliconedacron hinge prosthesis. Design, evaluation and application. Ann. Rheum. Dis., 28 (Suppl.), 56–8. Ruther, W., Verhestraeten, B., Fink, B. and Tillmann, K. (1995). Resection arthroplasty of the metacarpophalangeal joints. J. Hand Surg., 20B, 707. Sigfusson, R. and Lundborg, G. (1991). Abductor pollicis longus tendon arthroplasty for treatment of arthrosis in the first carpometacarpal joint. Scand. J. Plast. Reconstr. Surg. Hand, 25, 73–7. Sorial, R., Tonkin, M. A. and Gschwind, C. (1994). Wrist arthrodesis using a sliding radial graft and plate fixation. J. Hand Surg., 19B, 217. Swanson, A. B. (1972a). Flexible implant arthroplasty for arthritic finger joints: rationale, technique and results of treatment. J. Bone Joint Surg., 54A, 435–55. Swanson, A. B. (1979). Flexible implant arthroplasty of the proximal interphalangeal joint. Ann. Plast. Surg., 3, 346–54. Swanson, A. B. (1995). Pathomechanics of deformities in hand and wrist. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 1315–27, Mosby. Swanson, A. B., Swanson, G. de G. and Leonard, J. B. (1995). Postoperative rehabilitation programs in flexible arthroplasty of the digits. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 1351–75, Mosby. Tonkin, M. A., Hughes, J. and Smith, K. L. (1992). Lateral band translocation for swan neck deformity. J. Hand Surg., 17A, 260. Terrono, A. L., Millender, L. H. and Nalebuff, E. A. (1990). Boutonniere rheumatoid thumb deformity. J. Hand Surg., 15, 999. Terrono, A. L., Nalebuff, E. A. and Philips, C. A. (1995). The rheumatoid thumb. In Rehabilitation of the Hand: Surgery and Therapy (J. M. Hunter, E. J. Mackin and A. D. Callahan, eds) pp. 1329–43, Mosby. Watson, H. K. and Weinzweig, J. (1999). Intercarpal arthrodesis. In Green’s Operative Hand Surgery (D. P. Green, R. N. Hotchkiss and W. C. Pederson, eds) pp. 108–30, Churchill Livingstone.

15 The complex hand injury

Introduction
Complex injuries of the hand are those that involve varying degrees of tissue loss; this can include skin, tendons, nerves, vessels or bone. Digital loss frequently occurs with these injuries which can result from a crush, burn, an explosion, highpressure injection, gunshot wound or from severe infection. The injury can involve either the dorsum of the hand, the palmar aspect of the hand, or both hand surfaces (Fig. 15.1). These are open injuries with risk of infection and interruption of the healing process. Complex injuries with the best prognoses are those involving the dorsum of the hand only. The worst prognosis is associated with volar hand injuries where there is loss of skin, flexor tendons and digital nerves. Surgical and therapeutic management of these patients can last for many months and may involve numerous reconstructive procedures. Treatment decisions will need to be based on the individual circumstances of the patient. Factors that will influence these decisions will include: the patient’s age, occupational needs, ability to co-operate with protracted aftercare, leisure pursuits and financial situation.

ical, emotional, psychosocial and financial consequences of many complex hand injuries can be devastating. Occupational retraining is frequently necessary. The patient will need to make enormous adjustments, sometimes over several years, in all of these areas.

Patient education
Education of the patient is a very important component of the aftercare programme. Therapy measures, i.e. exercise, splinting, scar management and functional activity, do not take place in the therapy environment alone. They need to be maintained consistently on a daily basis. The patient and relevant family members will need to understand the rationale, sequence and frequency of use of the various therapy measures. The patient should demonstrate the exercise and splinting regimen to the therapist to ensure that there is full understanding of their application. Regular review is important so that modifications to the programme can be made commensurate with progress.

Treatment Psychological considerations
The patient’s reaction to the injury will warrant as much attention by treating staff as the actual injury (Brown, 1999). These patients require much encouragement and reassurance. Where indicated, formal counselling should be provided. The physThe primary medical and surgical management of these injuries will often determine the ultimate outcome of hand function. These injuries warrant specialist care and patients should be transferred to a specialist unit after their condition has been stabilized.

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(a) Figure 15.1. (a) This 28-year-old electrician sustained a crush/degloving injury to the dorsum of his left dominant hand while at work. (b) Following debridement and K-wire fixation of the fractures to the index and middle finger metacarpals, the defect was covered with a groin flap. Thinning of the flap and extensor tendon reconstruction were performed at a later date. (c) Some months later the patient underwent further elective surgery that involved transmetacarpal amputation of the middle finger and fusion of the index finger MCP joint to provide a stable and pain-free pinch grip. Full interphalangeal joint flexion provided a ‘hook’ grip in the absence of MCP joint flexion. This patient was unable to return to his preinjury occupation and retrained in computer studies.

(b)

(c)

1. Restoration of blood flow The first consideration in management of the complex injury is restoration of blood supply. The signs of arterial insufficiency include pallor, decreased temperature, increased pain and loss of pulse. Major arteries should be repaired; however, venous repair is seldom required. Major hand injuries are often accompanied by extreme oedema and the hand is monitored for signs of compartment syndrome which will warrant decompression of the forearm, carpal tunnel or hand spaces. 2. Prevention of infection Prevention of infection is of paramount importance and includes the following measures: (i) Antibiotics and tetanus immunization Wounds are cultured at the time of debridement. Those patients whose wounds are deemed to be at risk of infection, e.g. bites, deep penetrating

wounds or contaminated wounds following a crush or mangling injury, are started on intravenous antibiotics. (ii) Wound debridement The purpose of debridement is to decrease the risk of infection and to prepare the damaged tissues for healing (Haury et al., 1978). Debridement involves cleansing of the wound and the removal of foreign bodies and devitalized tissue. Potentially tight compartments, e.g. the carpal tunnel, are left open after debridement and closed when swelling has subsided. Cleansing is carried out using low-force pulsating jet lavage (Brown, 1995). A second debridement several days later will allow time for demarcation of non-viable tissue. (iii) Wound care Following debridement the wound is covered with paraffin gauze and multiple gauze swabs to form a

The complex hand injury

205

bulky dressing which extends from the elbow to the tips of the fingers. Gauze is also placed between the finger webs. The hand is held in the ‘position of function’ with a plaster, i.e. wrist slightly extended, the MCP and IP joints slightly flexed and the thumb in palmar abduction. If there has been extensive damage to the dorsum of the PIP joints, the hand should be kept in the ‘position of safe immobilization’, i.e. MCP joints in maximum flexion and IP joints in maximum extension. The forearm is then supported on a pillow or foam wedge with the hand held slightly higher than the heart. Where a skin graft or flap is not indicated, wounds are left unsutured and allowed to heal by secondary intention. Careful wound management is integral to preventing infection and controlling scar formation. An adherent dressing should never be forcibly removed as this will result in further trauma. Wound trauma, pain and the associated distress can impact on the wound microenvironment and potentially impair healing (Hunt and Hussain, 1992). In the case of grafts or flaps, pressure and shearing forces are avoided for the first 2 postoperative weeks. 3. Restoration of skeletal stability Tendons have a great propensity to become adherent if they are not taken through their gliding amplitude. For this to be possible, the skeleton

must be stabilized as quickly as possible so that movement can be initiated. Reduction of fractures and dislocations should ideally occur within hours or days of injury before oedema and fibrosis make reduction increasingly difficult. While reconstruction of skin, tendons and nerves can be deferred, reconstitution of the skeleton is a priority (Swanson et al., 1991). If there has been direct traumatic bone loss or severe comminution, primary corticocancellous bone grafting will be necessary. Fixation with K-wires is versatile and has relatively few complications. Rigid internal fixation with plates, screws and cerclage wires is gaining greater acceptance as the ‘hardware’ and techniques have become increasingly refined. Their use, however, does necessitate the availability of proper instruments and training in their application.

4. Wound closure The timing of wound closure will depend on the condition of the wound, soft tissue availability and reconstructive considerations. Where there is any doubt about the success of wound closure, it should be delayed (Burkhalter, 1985). Wounds that are properly cared for can be safely left open for many days and will usually fare better when managed in this way. The risk of infection is greatly decreased when reconstruction is deferred in the case of the contaminated wound. Where there is exposure of other structures, i.e. tendons and nerves, these must be kept moist with appropriate dressings. An open wound does not preclude mobilization of the fingers where this is not contraindicated, e.g. as in the case of skeletal instability. Planned skin coverage, such as a pedicled flap or soft-tissue transfer, can be undertaken when the wound is considered ready (Chow et al., 1986 and Godina, 1986).

5. Reconstruction
Figure 15.2. The skeleton is stabilized as quickly as possible so that movement can be initiated. This 50-year-old cabinetmaker underwent replantation of the right middle and ring fingers and digital nerve repair to the index finger after a circular saw injury. Gentle early protected movement was commenced after 7 days when vascular stability had been achieved.

The type of reconstructive procedure undertaken will vary from patient to patient depending on specific tissue loss. Procedures can include muscle-tendon reconstruction, tendon transfer, nerve grafting or flap debulking (Buechler and Hastings, 1999). These procedures are performed when maximum soft tissue and joint mobility have been achieved.

active movement can be carried out with more ‘vigor’. This 30-year-old insurance worker sustained a two-thirds radial-sided amputation of the left wrist from a circular saw injury that occurred in his home workshop. preferably while the hand is still in its initial dressing. The degree of damage in complex injuries can vary significantly. Hand therapy should begin as soon as possible. In the absence of tendon repair and where there is skeletal stability. the principles and aims of treatment remain the same. A ‘step-bystep’ therapy prescription can therefore not be given. While treatment of complex injuries will often require application of the full therapy armamentarium.4. carpal ligament reconstruction and repair of multiple flexor/extensor tendons and the median and radial nerves. grafting or flaps. The hand should be elevated at all times and active motion should be commenced as soon as possible unless contraindicated. Active exercise should be performed in a systematic fashion that Figure 15. The degree of damage sustained by the hand following a complex injury can vary significantly from one patient to the next (Fig. Many hand specialists now allow the commencement of early protected active motion after tendon repair.206 The Hand: Fundamentals of Therapy Hand therapy The complex hand injury. particularly those resulting from a crush injury. Gentle compression bandaging can be initiated in the absence of vascular compromise. This is particularly important following a complex injury where the risk of adhesion is greatly increased. Where this persists. This applies particularly to the shoulder joint of the older patient. Each case will require careful evaluation and the treatment programme will need to be tailored to the individual. Appropriate pain relief should be provided to enable the patient to co-operate with treatment. . are accompanied by gross oedema. An MCP joint blocking splint is used 1 to 2 hourly during the day. is characterized by adhesion formation and subsequent joint stiffness. soft tissue fibrosis and joint stiffness are inevitable. Early active motion All upper limb joints that have not been directly involved in the injury must be put through range of motion exercises regularly throughout the day.3). Stabilized movements are more effective in promoting differential flexor tendon glide. It is easy to focus on the hand only when damage there has been extensive. Surgery involved ORIF of a number of carpal bones and distal radius. Figure 15. regardless of which tissues have been involved. these being: uncomplicated wound healing.3. Oedema management Many complex hand injuries. 15. The reader should refer to the relevant chapters for the treatment protocols used following tendon repair. early movement and restoration of function.

If indicated. Excessive force can result in damage to healing structures. e. tendons. an MCP joint blocking splint to negate the effect of the intrinsic muscles and thereby isolate the extrinsic finger flexors. The reason for this is two-fold: 1. 6. The patient developed a compartment syndrome and required forearm and hand fasciotomies. Where splinting needs are complex. Dynamic MCP/IP joint flexion splints (Fig. The patient should experience only a mild stretching sensation rather than pain. For example. 2. 1995). The patient’s individual response to corrective splinting needs to be carefully monitored. Splinting Splinting. Conversely. The frequency of treatment sessions and number of repetitions can be increased commensurate with improvement. The corrective force applied by the splint should initially be negligible. Exercise putty can be used several times a day for short exercise sessions that are interspersed with functional activities. 2. 15. a dynamic flexion splint can be used to provide resisted extension exercises. the MCP and DIP joints are maintained in maximum extension throughout the manoeuvre (Stewart. Corrective splinting is only begun when the treating surgeon has been consulted. to protect the extensor mechanism during passive flexion exercises of the PIP joint. they should be performed with great caution. is integral to the management of the complex injury. Commonly used splints 1. nerves. Also. 8. Dynamic Capener splint for PIP joint flexion deformity.The complex hand injury 207 does not involve merely wriggling the fingers every now and then.5).4). 5. The patient tends to fatigue quickly at this early stage so overexercise should be avoided. A compression glove worn beneath the splint controlled oedema and provided scar compression. His dynamic flexion splint incorporated a padded lumbrical bar to address MCP joint stiffness. 3. 4. splinting takes on a corrective role as the remodelling scar tissue declares itself in the form of soft tissue tightness/contracture and joint fibrosis/stiffness. Passive movements are avoided during the early stage of therapy to protect injured structures. The session can be completed with composite fist-making exercises. As a precaution. e. i. several of these splints can sometimes be incorporated into one. Soft splinting.g. Blocking splints to facilitate specific tendon glide. Dynamic extension outriggers for PIP joint flexion deformity. Both static and dynamic splints are used to address these problems. Stabilized movements are more effective in promoting differential tendon glide (Fig. C-splint to overcome contracture of the thumb web. Initially. a neoprene finger stall to overcome IP joint flexion deformity. Resisted exercises are initially gentle and increased week by week. static splints are used to immobilize. support and protect the hand.e. a dynamic PIP joint extension outrigger can be used to provide resisted flexion exercises. 7. When sufficient healing has occurred.5. Figure 15. This resulted in fractures of the radius and ulna. swelling or an inflammatory response. splinting should not result in undue pain. the joints proximal and distal to the joint being moved can be held in protected positions. when permitted (usually around week 8). Muscle strengthening and endurance training are incorporated into the programme from about the 6th week. Simultaneous dynamic traction was applied to the interphalangeal joints via nylon filament and rubber bands attached to hooks that were glued to the fingernails. e. vessels or bone. Serial static volar extension splints to overcome flexor tightness.g. both static and dynamic. Serial wrist casting into extension. a dynamic flexion or extension outrigger can incorporate a dynamic thumb extension component. 15. Active stabilized flexion/ extension exercises of individual digits and joints are performed every 1 to 2 hours with 5 to 10 repetitions initially. This 35-year-old process worker sustained a roller crush injury to his right forearm.g. .

i.e. The static base of the splint provides a gentle corrective stretch to the thumb MCP joint while the outrigger applies gentle traction to the IP joint. Splints should be removed regularly during the day so that the hand can be used (Fig. 15. silicone gel sheeting is used beneath a pressure glove (Fig.7). Some form of compression should be applied to scar tissue almost around the clock. The intensity of massage can gradually be increased as skin tolerance improves. 15. Night splinting generally addresses extension range while day splinting aims to increase flexion range. 2000). Because scar maturation can continue for many months. . 15. Where scar tissue is particularly dense. some scar softening will be noted. Splints should be worn during sleep and intermittently throughout the (a) (b) Figure 15. the area is covered with Opsite Flexifix (Boscheinen-Morrin and Shannon.3). the proximal joints can be placed on slight stretch with the static splint base while a dynamic component directs a corrective force at the more distal joint(s) (Fig. e. Where the contracture results primarily from soft tissue shortening rather than being specific to a joint. The hand can be used with the glove or gel in place and splinting can be applied over these materials. Even when Opsite is used alone. This can be achieved with a pressure glove.9). If scar sensitivity is a problem. the patients are advised to maintain compression therapy for at least 3 to 4 months. 15. Where this is the case. Splints can simultaneously provide a static and dynamic force.6. Scar management Therapy measures to influence collagen formation should be employed as soon as wound healing is complete. The splinting timetable will need to be adapted to each individual’s needs. (a) Early stage of therapy: this outrigger splint applied gentle dynamic traction to the interphalangeal joints of the fingers while the thumb underwent serial static splinting that was strapped onto the outrigger (see Figure 15. Oils and creams used for massage should be fully removed prior to application of the pressure garments or silicone gel. (b) Later stage of therapy: soft tissue ‘clawing’ of the digits was gradually overcome with sustained dynamic and static extension splinting. splints will need to be alternated regularly. silicone gel sheeting. Figure 15. Complex hand injuries frequently result in restriction of both flexion and extension range.7. 1979) (Fig.3). Gentle scar massage is carried out regularly during the day to soften scar prior to exercise and as a means of desensitization. from about the 3rd week onward. a neoprene garment or fingerstall or silicone elastomer moulds (Kirscher and Shetlar. This dynamic outrigger splint was used to correct tightness of flexor pollicis longus (see Figure 15.8). Other materials are then applied over the Opsite layer. following repair of multiple tendons at the wrist.6).208 The Hand: Fundamentals of Therapy day.g.

Discharge from formal therapy should not occur suddenly. Modification of everyday utensils such as cutlery. modification of equipment may be necessary. stamina and strength improve. Patients are advised to protect grafts and flaps from the sun.8. the residual functional deficits are usually apparent by this time. Others become so depressed that decisions over even the simplest daily matters are beyond their capabilities.The complex hand injury 209 Figure 15. In some cases. comb. Figure 15. Formal therapy visits should therefore be scaled down gradually to enable the patient to make the necessary emotional adjustment. If return to pre-injury work is not feasible. Patients with major hand trauma can be anxious about leaving the protective therapy environment. vocational assessment and retraining options will need to be explored. may be necessary until a functional flexion range has been restored. Again. The outlined area on the radial aspect of the index finger denotes area of Opsite application (see Figure 15. Silicone gel is used to manage dense scar tissue.9.. . Even when there is little to do in terms of hand therapy procedure. Functional activity The patient should use the hand for light self-care tasks as soon as possible. A vocational rehabilitation officer should become involved as soon as the acute and subacute stages of therapy have been completed. these modifications will be permanent. A pressure glove controls oedema. provides scar compression and protects the hand when the patient returns to work. The patient is encouraged to attempt increasingly challenging tasks around the home as endurance. etc. toothbrush. Scar maturation varies from person to person and some patients will demonstrate a pale and flat scar several weeks after starting scar management. The palmar areas of the glove can be reinforced with leather for extra protection and to extend the life of the glove. Opsite Flexifix is applied to areas of hypersensitivity or the paraesthesia that is associated with nerve regeneration. The area should ideally be covered for full protection or a block-out sunscreen should be used. Even though further reconstructive surgery may be scheduled. These patients can leave the gel or garment off for several consecutive days to determine whether the scar has ‘regressed’ and requires further treatment. the reassurance and encouragement that the therapist continues to provide are an important element of the patient’s overall care and ultimate recovery. Referral to a psychologist or psychiatrist is a priority in both situations.2). Some patients have unrealistic perceptions of either their ultimate functional outcome or their choice of alternative career. Return to pre-injury hobbies and sporting activities is encouraged.

J. 274–81. B. Wound microenvironment. P. (1985). 135. Williams & Wilkins. 285–92. Davis. Haury. Ther. P. 1607–30. Open hand fractures: prognosis and classification. Buechler. Reconstr. Tech. J. Reconstr. Bilos. Churchill Livingstone. . Callahan. eds) pp. Trauma. (1986). Green. Simplified wound lavage. Lindblad.. (1984). J. D. Debride- Further reading Conolly. E. J. R. Vensko. N. G. 241–57.. Diegelmann and W. Early microsurgical reconstruction of complex trauma of the extremities. M. 99–118. H. and Shetlar. Opsite Flexifix: an effective adjunct in the management of pain and hypersensitivity in the hand. J.. (1979). (submitted September. T. V. Hunt.. Z. B. V. 154. M. J. 1631–50. A. W. Chow. et al. Mutilating injuries. Pederson. R. P. L. F.. Jr. 1057–73. (1995). C. J. U. In Green’s Operative Hand Surgery (D.. L. Churchill Livingstone. C. J. Saunders. In Green’s Operative Hand Surgery (D. Surg. J. Complex injuries of the hand. (1978). Orthop.) pp. 2000).. K. Swanson.) pp. W. (1995). (1991). S. Occup. M. In Wound Healing: Biochemical and Clinical Aspects (I. R. K. eds) pp. II. In Mutilating Injuries of the Hand (A. In The Hand and Wrist: Current Management of Complications in Orthopaedics (S. J. K. 77.. (1999). Biophysical principles of heating and superficial heat agents. The groin flap in reparative surgery of the hand. Hui. et al. C.. (1992). P. Hotchkiss and W. Aust. Surg. C. Churchill Livingstone. N. 238–42. Am. Pederson. In Thermal Agents in Rehabilitation (S. Hotchkiss and W.210 The Hand: Fundamentals of Therapy ment: an essential component of traumatic wound care. Plast. D. 10. J. In Rehabilitation of the Hand: Surgery and Therapy (J. C. 15–26. Morrin. Mackin and A. P. Hand Surg. Burkhalter. Surg. and Hussain. and Anderson. E. and Shannon. Green. R. 757. Brown. Hunter. W. ed. W.. (1986). eds) pp. Mosby. Therapist’s management of the complex injury. Plast. 421–5. and Hastings.. A. (1999). W. Sandzen. T. 101–7. 16A. eds) pp. M. Cohen.. J. Combined injuries. Brown. ed. Kirscher. D. Szabo. Open injuries of the hand.. Microvasculature in hypertrophic scars snd the effects of pressure. References Boscheinen-Morrin. W. Godina. 78. Stewart. F. Tubiana. (1986).. Campbell Reid and R.. W. B. 19. Michlovitz. (2000). eds) pp. Rodeheaver. and Davey. Z. Michlovitz.

The greatest problem with pedicled reconstructions. 4. free tissue transfer is most commonly used to provide soft tissue cover. Where there is exposed bone. where the defect cannot be closed by a skin graft. By definition. These situations include: 1. free tissue transfer is an option in those situations where flap coverage is required. in one stage. they require two surgical procedures and are therefore time-. to a recipient site where its circulation is restored by microvascular anastomoses. these procedures do have shortcomings. Less commonly. Pedicled groin flap reconstructions of hand defects are often left for 2 to 3 weeks before flap division. is the enforced immobilization of the reconstructed part. are too bulky for reconstruction of the dorsum of the hand or forearm and require further procedures to defat or liposuck the flaps to optimize their contour. devoid of periosteum. Most of the larger flaps. free flaps are used to provide vascular conduits where there has been disruption of critical vascular inflow and outflow. 2. Where there are tendons without their overlying paratenon. labour. Introduction Microvascular free tissue transfer allows reconstruction of complex hand defects. Only minimal shoulder. can result in PIP joint flexion contracture and stiffness after only 7 to 10 days of immobilization. Adequate precedent has now been established for using free flaps as the definitive form of soft tissue cover in the upper extremity in emergency situations. however.e. Soft tissue coverage When covering a soft tissue defect in the upper extremity. such as a crossfinger flap. Where vessels or nerves have been reconstructed. such as the pedicled groin or abdominal flaps.16 Microvascular free tissue transfer James Masson Definition A free flap is a composite block of tissue that is surgically removed from a donor site in the body and transferred. i. 3. It is also used in skeletal reconstruction and in the provision of functioning muscle units. . elbow and hand mobilization is possible and this is an especially worrying situation in the case of the elderly patient. Conventional two-staged pedicled procedures Although capable of producing a similar end result. Postoperative oedema and stiffness are compounded by the position of forced dependency of the hand following this procedure.and cost-intensive. In the hand and upper extremity. Where there is cartilage devoid of perichondrium. A relatively simple procedure.

16. The contour of the defect. however.1). These procedures can be lengthy and. Radial and ulnar forearm flaps These flaps are based on the arteries after which they are named. leaving a large depression on the volar forearm. unlike some pedicled reconstructions which can undergo varying degrees of ischaemic necrosis at their tips. Once again. Groin The same skin that is used in a pedicled groin flap can be elevated as a free flap. Scapular and parascapular flaps Choice of free flap The choice of free flap for soft tissue cover will be determined by: 1. The transfer is performed at one operative procedure. consideration has to be given to the prevention of intra-operative pressure areas. The scapular and parascapular flaps are based on the same primary vascular axis as the latissimus dorsi muscle. Skin from these sites is thin. which must be grafted. 2. A very large piece of skin can be harvested from this site whilst still allowing primary closure of the donor site which is well hidden near the groin crease. The tissue that is transferred can be selected so as to most closely resemble the requirements of the recipient site defect whilst minimizing donor site morbidity. The other concern. 2. normal postoperative elevation is possible and the hand can be readily placed in the position of safe immobilization. In most published series. Sacrifice of the posterior cutaneous nerve of the forearm. 4. The greatest risk of microvascular surgery is vascular thrombosis and flap loss. 3. is the sacrifice of one of the major vessels to the hand. 2. nerve palsies and deep venous thrombosis. the donor site can normally be closed in a linear fashion. These two skin flaps from the back have enjoyed some favour. based on either the superficial circumflex iliac or the superficial inferior epigastric vessels. The first web space flap of the foot . As long as the flap is no wider than 6 cm. so flap loss should be a rare occurrence. however. apart from the fiscal restraints that this might incur. Lateral arm flap The lateral arm flap provides skin of a similar consistency to the forearm flaps. Problems associated with free tissue transfer 1. the nature of the wound. but fascial flaps and muscle flaps also have a place. Depending on the nature of the reconstruction that has been performed. The major disadvantage of these flaps is the donor site. Transferred tissue has a predictable vascularity. 1. large areas of skin can be elevated. The size of the defect. Microvascular technical skill and equipment are not available everywhere. the flap survival rate for elective free tissue transfer should now be 97 per cent or greater. Neurovascular first web space flaps Critical sensibility of the fingertip can be restored by free neurosensory flaps or microvascular toepulp transfer. 2. 5. 3. As with the pedicled version. relatively hairless and is well suited to resurfacing defects on the dorsum of the hand and forearm. which has more academic than clinical significance. The large calibre of the vessels makes these transfers very reliable. the flaps tend to be a little fat and the donor site scar on the back often stretches out.212 The Hand: Fundamentals of Therapy Advantages of microvascular free tissue transfer These include: 1. especially away from major teaching institutions. 5. As the hand is not bound to any other part of the body. early postoperative mobilization is possible. 3. however. does lead to loss of sensibility distal to the elbow and this is troublesome in some patients (Fig. secondary defatting is often required. leaving an acceptable donor site. Fasciocutaneous flaps Fasciocutaneous flaps are the most commonly used. 3. As with the groin flap. 4. but avoids sacrifice of a major vessel.

It is supplied by the first dorsal metatarsal artery (FDMA). the search for a tissue source that avoids these problems was undertaken. (d) consists of the lateral aspect of the great toe and the medial aspect of the second toe. or second toe. can be reconstructed with a free. Fascial flaps satisfy both these requirements. the longevity of these reconstructions remains to be seen.Microvascular free tissue transfer 213 (a) (b) (c) Figure 16. Thumb loss. a branch of the dorsalis pedis artery. Vascularized toe joint transfers have been used to replace destroyed PIP and MCP joints. The main advantage of the first web space flap for sensory reconstruction in the hand is replacement of pulp skin with similar thin. or the first plantar metatarsal artery. (d) The defect was covered with a fasciocutaneous lateral arm flap. (b) The middle finger has been transferred to the base of the thumb. 16. Fascial flaps Because some of the commonly used fasciocutaneous flaps are either too fat for dorsal hand reconstruction or leave an unacceptable donor site scar. (a) Oblique transmetacarpal amputation of the left hand.1. Its innervation is through both the deep peroneal nerve and the medial plantar nerve. The toes are the source of many free flaps for reconstruction of the hand. (c) Design of lateral arm flap.2). glabrous skin with concentrated sensory receptors. especially at. This allows the best chance for restoration of functional sensibility. however. whole great toe. The second and third toes can be used to reconstruct missing fingers in certain congenital and post-traumatic conditions (Fig. They have several advantages: . or proximal to. the MCP joint.

3. Muscle flaps have a better vascularity than fasciocutaneous flaps and are more readily able to deliver antibiotics to infected. For the most part. 1.214 The Hand: Fundamentals of Therapy (a) (b) Figure 16. silicone scar gel. gracilis is useful in long. The muscle selected will be determined by the size and contour of the defect. pliable cover without bulk. the volar hand and wrist and in the first web space. pressure therapy. For small defects. Occasionally. posttraumatic defects (Fig. The radial and ulnar forearm flaps and the lateral arm flap can also be raised as fascial flaps only. taking a piece of tissue as large as 14 10 cm. They are useful where a gliding surface is required for tendons and nerves. 16. For this reason. Similarly. This is especially the case in large. the area is rested for the 1st postoperative week after which gentle movement is begun. thin defects. . or potentially infected wounds. To prevent hypertrophic scarring. they leave an inconspicuous donor site scar. alopecia should not be a problem. they are useful in the management of chronic osteomyelitis. especially following release of extensive contractures. leaving a linear donor site scar. the serratus anterior is useful as it has a long pedicle and minimal donor site morbidity.2.g. (a) Defect resulting from a fan blade injury to the left hand.3). skin graft ‘take’ can be variable due to haematoma formation beneath them. is instituted after 3 weeks. Muscle flaps The malleability of muscle flaps makes them well suited to difficult contour problems in the upper extremity. The only problems with these flaps is their relatively limited size and the fact that they require a skin graft to cover them. The temporoparietal fascia can be harvested as a free flap. Aftercare following fascial flaps Following free fascial flaps. 4. Fascial flaps are used most commonly for defects on the dorsum of the hand. 2. They are readily contoured to the defect. (b) A good functional result was achieved following transfer of the second toe to the ring finger. e. They provide thin. The donor site is hidden beneath the hair and providing that care is taken during elevation of the flap.

(d) For wounds of moderate size.3. certain clinical situations in which the technique will not . however. Despite its size. the following primary tendon transfers were performed. The latissimus dorsi muscle is used where a large area or volume of muscle is required.Microvascular free tissue transfer 215 (b) (a) (c) Figure 16. Skeletal reconstruction Conventional non-vascularized corticocancellous bone grafting is the most common technique used for reconstructing bony defects in the upper extremity. Brachioradialis was used to restore function of flexor pollicis longus and extensor carpi radialis longus was used to restore function of flexor digitorum profundus. There are. (b) Radical debridement of the ischaemic tissue resulted in substantial loss of flexor musculature. its loss results in minimal morbidity for the patient. Careful abdominal wall closure should minimize the risk of postoperative herniation and weakness. (d) To restore flexor function. (c) Elevation of right latissimus dorsi muscle flap. The transfers were covered with a latissimus dorsi free flap and split skin graft. the rectus abdominis is well suited. (a) This acute infective compartment syndrome of the left forearm occurred after a pitch fork injury.

are probably more appropriate in this setting. or as a result of debridement after infection. and is the appropriate length for both of these reconstructions. brachial plexus injuries) or muscle injury (e. either following trauma. It will usually take 6 to 8 weeks to re-establish the preoperative passive extension range. Alternatively. It is expendable in the leg. and has been so described in reconstruction of scaphoid non-unions.g. Depending on how far from the hilum of the muscle the donor nerve has been divided. The motor nerve to the muscle must be coapted to an appropriate recipient motor nerve in the upper extremity and the new origin and insertion of the muscle must be re-established under appropriate tension. The exercise programme should be continued for at least 12 months after the return of movement. muscle or tendon transfers might restore some of the lost function. . It can also be used at the forearm level to restore finger flexion. Fibula The fibula is the most common source of vascularized bone for long bone defects. the iliac crest can be harvested on a vascular pedicle. Where muscle function is lost through nerve injury. Chronic non-union of long bones. In the same way. the gracilis muscle is well suited for restoration of elbow flexion. release of the contracted muscle mass with a muscle slide or transfer of tendons. Up to 30 cm of primarily cortical bone can be harvested. the transplanted muscle is placed in a relaxed position with the wrist and finger MCP joints splinted in moderate flexion so that there is no tension between the flexor tendons and the transplanted muscle. Functional muscle flaps Muscle function can be irreversibly lost through nerve damage (e. where there are insufficient motors to restore the functions required. Aftercare for restoration of finger flexion During the 3 week immobilization period. to produce a ‘doublebarrelled’ reconstruction. is then commenced. osteotomizing the bone in this way increases the volume of bone and the strength of the reconstruction. The exercise and activity programme is gradually upgraded commensurate with progress. 3. 2. might restore active finger and thumb flexion. however. Other muscles which have been used for these functions are: the latissimus dorsi. the tensor fasciae latae and the medial head of the gastrocnemius. based on the peroneal vessels. with minimal morbidity from its harvest. More simple pedicled options from the dorsum of the wrist. Gentle passive finger flexion and active IP joint extension is commenced after 5 to 7 days when vascular stability has been achieved. Radius and iliac crest Although it is possible to harvest part of the radius with a radial forearm flap. the fibula can be osteotomized. with gravity eliminated. however. These situations include: 1. There should be consultation with the treating surgeon prior to commencement of these exercises. In these situations. There comes a point. Reconstruction with vascularized bone is then required. some flicker of activity should be evident by about 3 months. it is sometimes possible to restore some function by nerve repair. In the case of Volkmann’s ischaemic contracture. which will be about 50 per cent of normal. The aim is to obtain full passive muscle extension and to improve tissue gliding at the musculo-tendinous junction in readiness for active exercise upon reinnervation. Volkmann’s ischaemic contracture). In children. Maximum strength. due to the segmental nature of its blood supply. Active exercise.216 The Hand: Fundamentals of Therapy predictably produce bony union. Gentle passive stretching of the wrist and fingers is begun between 4 to 6 weeks after surgery. Long bone defects of greater than 6 cm. the volume of bone so obtained is relatively small and there is significant risk of subsequent fracture of the donor bone. Where required. In brachial plexus injuries. Although the fibula will hypertrophy to near the size of the surrounding bone under stress anyway. such as in the humerus. will take approximately 2 years to achieve. Regular stretching exercises can be augmented with gentle prolonged stretch using serial splinting. new motors will need to be ‘imported’. Defects following tumour excision. grafting or transfers. where traditional grafting procedures have failed.g. especially when supplemented with radiotherapy. the cartilaginous head of the fibula can be harvested in continuity with the bone to reconstruct the distal end of the ulna.

3. Reduction or elimination of secondary operative procedures. 13A. low-dose aspirin) to prevent thrombosis of the microsurgical anastomoses. Surg.. (1992). Wound debridement. C. Emergency free flaps to the upper extremity. In Green’s Operative Hand Surgery (D. Foucher. F. Plast. Plast. L. where necessary. R. G.. free tissue transfer. Hand Surg. Although the skeleton and soft tissues might well be reconstructed successfully. Godina. there are well established principles of surgical management. at about 14 days. Vascularized joint transfers. Assessment includes: flap colour.. The patient and their environment are kept warm and the patient should abstain from caffeine and nicotine. immobilization and resultant loss of motion. R. Where healing progresses uneventfully. and Scheker. Many surgeons use anticoagulants (e. (1999). 2. the limb is protected with a windowed non-constricting slab during sleep. 2. J. T. Reconstr.. Restoration of skeletal stability. G. J. Pederson. Churchill Livingstone. if not better than. S. and Lister. 89(6). (1999). Gentle compression with Coban wrap can then be commenced. Oedema control is limited to elevation for the first 2 weeks to prevent vascular compromise.. Significant reduction in infection and flap failure rates. eds) pp. Concerns of increased flap failure rates in the acute setting have not been borne out by published series which show survival rates equal to. All joints that are not included in the cast should be exercised. N. G. Tan. 1013–9. temperature and capillary refill. eds) pp. D. pulse oximetry and implantable venous Doppler probes are also useful. Surg. (1986). intravenous dextran 40 or heparin. et al. . Reconstr. Provision of soft tissue coverage. References Lister. and Zoltie. The hand is elevated to heart level only as extreme elevation may interfere with arterial flow. Wei. Lister. The patient should be ambulant as soon as possible after surgery. Soft tissue reconstruction.-C. Early microsurgical reconstruction of complex trauma to the extremities. Vessel. ideally on the first postoperative day. 16A. Further reading Chen. these steps have been performed as multiple staged procedures. When vascular status allows. Aftercare Following a free tissue transfer procedure. Pederson. L. L. Hotchkiss and W. Over the past decade. movement of involved joints can be commenced.. 62. N. Traditionally. F. P. 89(5). including. (1991). Chen. 598–604. This makes each subsequent procedure more difficult. In Green’s Operative Hand Surgery (D. Reduced hospitalization and associated medical costs. R. avoiding the need for subsequent procedures. Hand Surg. These are: 1. The use of the lateral arm flap in upper limb surgery. (1992). dealing with injury to the nerves. Toe-to-thumb transplantation. Where available. Emergency free-flap transfer for reconstruction of acute complex extremity wounds. P. removing dead or potentially dead tissue. Surg. Katsaros. 78(3). 1299–326.. N. the end functional result might not reflect the lengths and complexity of the surgery. H. D. The ability to provide immediate flap coverage means that reconstruction of underlying structures can be performed at the same time. In contradistinction. (1999). N. Hotchkiss and W. 882–8. there has been a trend towards performing the entire reconstruction within the first 24 hours after injury.. The main problem with the traditional management of complex post-traumatic hand wounds is that each operative step introduces more scarring. Gordon. Reconstr. elective free flaps. the flap is usually stable by 8 to 10 days after surgery. Churchill Livingstone.. 3. R. 1159–200. E. nerve. Green. Pederson. bone and tendon repairs or grafts can therefore be performed. Green. C.g. Jones. 285–92. Churchill Livingstone. and Sowder. C.Microvascular free tissue transfer 217 Emergency free flaps In complex hand trauma. Green. 4. In Green’s Operative Hand Surgery (D. eds) pp. vessels and tendons.. Plast. 1251–70. however. G. Early freeflap coverage of electrical and thermal burns. J. Hotchkiss and W. L. Chick. commencing with the work of Lister and Scheker (1988). H.-C. P. (1988). N. Free skin and composite flaps. M. No dressings are applied to the surface of the flap which is monitored every hour for the first 48 hours after surgery. the literature to date shows that the treatment strategy of performing the entire 3-dimensional reconstruction within the first 24 hours after injury has the following benefits: 1.

568–75. McC. M. H. D. Singer. (1993). (1997). B.218 The Hand: Fundamentals of Therapy O’Brien. Green. R. Hotchkisss and W. N. (1995). Management of skin grafts and flaps.. E.. N. J. 20B. Langley.. L. J. J. H. and Julliard.. Pederson. 18B. Martin. and Breidenbach. E. L. Free neurovascular flap from the first web of the foot in hand reconstruction.. Hand Clinics. Cohen. (1999). B. L. R. 2. Functioning free muscle transfers. R. C. Churchill Livingstone. Reconstructive Microsurgery. Scheker. eds) pp. 275–88. C. McC. The role of emergency free flaps for hand trauma. M. Mackin and A. Moore Jr. Hand Surg. M. Churchill Livingstone. I. In Rehabilitation of the Hand: Surgery and Therapy (J. S. Hotchkiss and W. W. eds) pp. P. 1201–19. R. May. Hand Surg. and Anderl. and Byron. Chait. Wei. Toe-to-finger reconstruction. J. 1327–52. (1987). Green. W.. J. Hand Surg. P... (1995). Manktelow.. Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps... McCabe. and Santamaria. (1999). T. J.-C. S. A. D. Hunter. A. Ninkovic. . E. 15(2). 277–90. 53–8. P. W. (1999). D. In Green’s Operative Hand Surgery (D. and Morrison. F. K. J. K. J. J. H. and Anastakis. Oehler. C. 387–93. Deetjen. M. and O’Brien. Mosby. N. Emergency free tissue transfer for severe upper extremity injuries. Churchill Livingstone. eds) pp. D. In Green’s Operative Hand Surgery (D. Pederson. Callahan.

While the first priority of treatment is to save life. Its exposed position means that it frequently comes in contact with hot objects. 1987). often look disastrous. The immediate effects of a tar burn. Rapid heat gain in the dermal and subdermal layers can therefore quickly overwhelm the microcirculation and progressive ischaemia is then added to the original thermal insult. tendons and joints and beyond the immediate area of the burn. 1995). Figure 17. good initial care of the hand is imperative if a favourable functional outcome is to be achieved (Sheridan. . liquids and numerous chemicals (Davis. however.17 The burnt hand Burns involving the hand can occur as an isolated injury. The appearance of the hand following a burn injury can be deceptive. which is the most common site for burns. The hand is at risk from burn injuries in many occupations. for instance. because tar cools quickly. has a thin subcutaneous layer and therefore poor insulation. Every burn is accompanied by inflammation and oedema. however. they are frequently associated with major burns to the body that constitute a medical emergency requiring respiratory and cardiovascular stabilization. infection is likely. Pathophysiology The dorsum of the hand. The hand has a relatively large surface area. Because there is damage to both the skin barrier and deeper tissue. All these factors predispose to fibrosis which may extend from the superficial layers to the muscles. The three depths of burn.1. the depth of the burn will be less than that resulting from fat or grease which will hold the heat for a longer period of time. This facilitates heat conduction to important deeper structures such as tendons and joints.

Wound coverage to the hand and arm was achieved with meshed split-thickness skin grafts. To eliminate all devitalized tissue. Electrical Superficial burns from an electrical short are generally flash burns rather than actual conductive electrical burns and are managed in the same way as thermal burns. Hydrogen fluoride is a common cleaning agent that is used in many industries. Figure 17. Immediate treatment involved open reduction and internal fixation of comminuted fractures of the radius and ulna. forearm and hand when his limb became trapped for 90 minutes in a conveyor belt. 1999). etc.g. with a radiator. e. High voltage currents result in necrosis of muscles. If the hands are used to extinguish flames. Friction burns Friction caused by moving machinery. 2. Severe electrical burns require urgent decompression and fasciotomy on the day of injury. Pain. 17. 1. 1992).1). Deep epithelial cells survive and spontaneous healing occurs within 2 to 3 weeks with a good functional and cosmetic result. Chemical burns should be extensively irrigated with running water as soon as possible. Erythema. several debridements are usually needed. hot plate. Degrees of burn injury The depth of the burn will determine whether the wound will heal spontaneously or will require grafting. 17. the volar aspect of the hands will be affected. True electrical burns are usually deep and. vasculitis and deep burns. they have an entrance wound and exit wound. Features of these burns include: (i) (ii) (iii) (iv) Swelling. The former generally occur on the backs of the hands when these are used to protect the face. hydrochloric. can cause deep burns (Fig. Such extensive debridement may necessitate flap coverage (Chick et al. Thermal burns Thermal burns are the most common and include flame and flash burns or contact with hot liquids. fasciotomies of the forearm and extensive wound debridement. Many burn injuries present with features from all three categories of burn. Superficial partial-thickness Superficial partial-thickness burns involve the epidermis and may also involve the upper dermis. generally involve the palmar aspect of the hand. Contact burns.220 The Hand: Fundamentals of Therapy Causes of burn 1. Contact with this chemical (usually at the finger tips) is painful and requires prompt treatment to avoid infiltration and inflammation of the distal phalanx (Achauer. objects or steam. Early excision may be required if the injury is sufficiently deep. rope or from the hand being dragged over a surface..3).. 4. Blistering. Chemical burns Prolonged contact with chemicals such as picric. Light dressings and a ‘position of safe immobilization’ splint are . Wound management Superficial burns can be covered with an antibacterial cream such as silver sulphadiazine and protected with a plastic bag during the day to allow the patient to carry out gentle active exercise and to perform self-care tasks (Fig. 3. whether from low voltage (domestic) or high voltage (industrial) currents.2. hydrofluoric and other acids and alkalis may saturate the skin and produce neuritis. This 25-year-old freight operator sustained a severe crushing and friction burn injury to his left upper arm. vessels and nerves beneath an apparently minor skin burn.

Complications related to burn injuries 1. 17. 2. Deep partial-thickness These burns involve damage to the dermis and epidermis. Skin grafting is therefore the preferred treatment option (Fig. The hand is cleansed daily in water and the wound is debrided of loose tissue. can result in a tourniquet effect. this disruption to circulation can result in ischaemic necrosis of muscles. . Those that have become infected have been contaminated by the subsequent environment or by organisms in the glandular or follicular elements of the unburnt tissue. they are prone to hypertrophic scarring which will compromise both function and cosmetic appearance. They have a grayish. intrinsic. Subsequent contracture. Buttonhole deformity is common following severe burns to the dorsum of the hand from damage to the extensor apparatus over the PIP joints. Superficial burns are coated with an antibacterial cream such as silver sulphadiazine cream. tendons and joints. A common complication of dorsal hand burns is a buttonhole deformity resulting from damage to the extensor apparatus over the PIP joint.3. Full-thickness burns These burns destroy the epithelium and superficial nerve endings and are therefore painless. Nail deformities are also common (Fig. Stiffness results from a combination of inflammation. 3. 4.2). radial or ulnar). oedema and fibrosis of healing tissues including skin. 3. While these burns can heal spontaneously. the burn may convert to a full-thickness injury. 2. this inelastic tissue. combined with oedema. The devitalized tissue resulting from deep burns is known as eschar. In the early postburn stage. 17. The hand is then covered with a loosely fitting plastic bag that is secured at the wrist and enables the patient to exercise and use the hand freely during the day. If the wound becomes infected. Swelling. the main problem is sepsis which can convert a simple superficial burn into a deep one. Ischaemia. Figure 17. waxy or charred appearance. nerve damage or gangrenous digits (deLinde and Miles.4). Most burns are surface-sterilized by the nature of the injury. Severe burns are usually accompanied by marked oedema due to increased capillary permeability and the large fluid loads usually needed to maintain intravascular volume (Achauer. tendons and joints. These burns do not heal spontaneously and will require grafting.The burnt hand 221 Figure 17. Sepsis. Unless relieved by escharotomy (digital. Where deep burns are circumferential. then applied at night. 1999). 1995). 5.4. Scarring of skin.

Palmar abduction of the thumb to avoid contracture of the 1st web space. the splint will require regular adjustment in response to oedema resolution and improved range of motion. Maximum flexion of the MCP joints. a buttonhole deformity may develop because of volar migration of the lateral bands. their normal permeability (deLinde and Miles.222 The Hand: Fundamentals of Therapy Skin grafting Skin grafting is indicated when healing has not occurred by the 3rd week. adduction of the thumb and flexion of the wrist. This deformity involves extension of the MCP joints (initially from marked dorsal hand oedema). Treatment Early medical/nursing care involves control of pain with appropriate analgesia. overuse of the splint should be avoided. the hand is splinted as closely as possible to the ‘position of safe immobilization’ (POSI). Oedema control Oedema is significant following most serious burns. Where burns to the body have been extensive and donor skin is scarce. systemic antibiotics. Restoration of full or maximum function. To counteract the ‘claw’ deformity commonly associated with burns. 2. For the management of deep burns to the palm. hence reducing the risk of permanent stiffness and decreasing the extent of scar formation (Mahler.. Therapy following burn injury Aims of treatment 1. To minimize the risk of stiffness. Formal therapy time and use of pressure garments is reduced following a fullthickness skin graft (Schwanholt et al. flexion of the PIP joints. 2. 1991). Unless grafts are in short supply. cadaveric dermis) or synthetic dermal substitutes can be used. In the early stages of management.5. Provision of psychological support. The hand should therefore be elevated at all times when not being exercised or used. particularly in the paediatric patient. Support splinting The most common deformity associated with more serious burns is the ‘claw’ deformity. The extensor tendons lie just beneath the thin dorsal skin and are therefore easily damaged. This splint will need regular adjustment as oedema subsides. 1993). it is held in place with gauze wraps rather than with compression bandaging which may compromise circulation at this very early stage. sheet grafts rather than mesh grafts should be used as these produce less scar tissue and provide a superior functional result (Achauer. Compression dressings are not used until about the 5th postinjury day when vessels are regaining The splint is worn at night and during periods of inactivity throughout the day. ‘Alloderm’ (i. anti-tetanus cover and wound/graft care. the use of full-thickness skin grafts is indicated. This position involves: (i) (ii) (iii) (iv) 20 to 30 degrees of wrist extension. Prevention of deformity. 1995). Dressings should be loose enough not to inhibit joint motion. Maintenance of joint mobility.e. 1987). the hand is splinted in the ‘position of safe immobilization’ when the hand is not being exercised or used. If the splint is applied in the first 3 to 5 days after injury. To counteract this posture. Wounds that are not healed by this time and which are allowed to granulate. The elimination of swelling is most important in minimizing the fibrosis that results from its persistence. Therapy management includes: 1. This can be achieved with elastic bandages applied to the hand and forearm and Coban wrap to the digits. gentle compression therapy is then begun. . Most burn injuries can be satisfactorily resurfaced with split-thickness skin grafts. the arm is supported with a foam wedge with the hand elevated to heart level (Rivers et al. By the end of the 1st week. 1999). this should be addressed with appropriate analgesia. the nature of the swelling will have changed from being very firm to having some ‘give’ when indented. 3. Initially. will inevitably result in hypertrophic scarring and contracture. Early grafting will facilitate rehabilitation. Where there is destruction of the central slip over the PIP joint. 4. Maximum extension of the IP joints. Figure 17. If pain is causing the patient to keep the hand splinted or immobile..

Corrective splinting As healing progresses. The fabric used in custom-made pressure gloves also provides an effective ‘extension’ force to the digits. e. If there is actual tendon exposure. Emphasis is on intrinsic flexion of the MCP joints and intrinsic IP joint extension. Over-enthusiastic passive manoeuvres will result in increased oedema. As pain decreases. the hand is rested in a POSI splint for 7 to 10 days until the graft is stable. In the case of deep burns. active (and very gentle passive) exercise is begun from the day of injury. active exercise sessions. This will usually involve: (i) MCP joint flexion splinting. Early active movement and function If skin grafting has been carried out. (ii) PIP joint extension splinting. 4. but will not be as disabling as an extension contracture of the MCP joints.g. when the more proximal and/or distal joints are relaxed. but frequent. Stiffness of the PIP joints is sometimes inevitable. Figure 17. During wound healing and subsequent scar maturation.. gross active flexion exercises can be accompanied by gentle overpressure into flexion. As soon as possible. Otherwise. The loss of skin mobility resulting from contracting scar on the dorsum of the hand will restrict global finger flexion although the range of movement of individual finger joints can be surprisingly good. the propensity to contracture will increase and corrective splinting is often required.The burnt hand 223 3. hand-based dynamic outriggers or Capener splints are used over the compression garment. otherwise. If disruption to the extensor tendon is managed conservatively. everyday utensils such as cutlery. 1994). The patient is encouraged to practise short. Where flexion deformities require a stronger extension force. the dynamic flexion splint can incorporate a lumbrical bar to flex the MCP joints while flexion force to the IP joints is achieved through traction applied to hooks that are glued to the fingernails (if these have not been involved in the burn). toothbrush. Passive manoeuvres can gradually become more ‘forceful’ as tolerated. This problem is addressed with dynamic flexion splinting which applies a force at the MCP and IP joints simultaneously. Also. Thumb web contractures are managed with serial C-splints or with dynamic extension splinting . 17. exercises that are performed actively (or actively assisted) are more effective in reducing swelling and in maintaining and regaining muscle strength. dressings that maintain moisture and encourage healing will need to be applied (Saffle and Schnebly. When stabilizing the hand during exercise. All exercises are carried out within pain-free limits. Active exercise is considerably less painful than passive exercise which should be performed slowly and with great care.e. To address this.6. Flexion deformities of the PIP joints can be managed with neoprene finger stalls which allow flexion and provide excellent scar compression. rather than on granulation tissue (deLinde and Miles. are enlarged with foam or other soft materials to enable grasp. etc. i. the hand should be used for light self-care activities. Where flexion range is restricted. gross gripping. the PIP joints are splinted in extension with a volar splint that permits MCP and DIP joint motion. support is given over areas of eschar (which is painless). maintenance of the web spaces and opposition of the thumb to all digits. haemorrhage and fibrosis. All upper limb joints should be moved regularly during waking hours. Exercises can initially be performed in a warm cleansing bath that will reduce pain and help facilitate movement. The wires can be inserted within a few days of injury and remain in place for 2 to 3 weeks while skin coverage is completed. (iii) Web spacers. temporary K-wire fixation of the PIP joints can help facilitate flexion of the MCP joints and protect vulnerable extensor tendons which may be prone to rupture. 1995).5). loops are gently applied to the distal phalanges (Fig. serial C-splinting to overcome a tight web space. the skin on the dorsum of the hand can contract quite markedly and limit digital flexion.

Patients are usually fitted with two gloves to enable regular laundering of the garment. psychological and economic consequences can be enormous. the palm of the hand. Scar that has fully matured is light pink or white in colour and fairly flat. Even minor burns with minimal cosmetic disruption can be devastating for some patients. Soft tissue contracture Contracture of the digital web spaces involves skin only and is corrected with a V-M-plasty. will lengthen this process.7. 1992). 1999). The glove should fit snugly but should not interfere with circulation. gauze or cotton wool. however. Corrective splints are worn over the glove. these garments can be ‘abrasive’ and result in skin breakdown. Reconstructive procedures Joint contracture The severely burnt hand with established PIP joint contractures is generally not amenable to tendon or joint reconstruction (Achauer. States of anxiety and/or depression will need to be addressed if the patient is to be able to comply with the treatment programme. Dynamic flexion splinting is instituted immediately after surgery. e. scarring and functional loss. loss of digits. the glove should incorporate a zipper. Adduction . i. When pressure therapy with a custom-made glove is commenced. These joints can undergo fusion in a functional position. red and tight. Tight finger web spaces can be gently stretched with foam. 5. This is in contrast to immature scar which is thick. These materials are unlikely to cause pressure areas and can be readily modified as the webs stretch. A custom-made pressure glove is fitted when grafts and wounds are fully healed. Silicone gel can be used in areas where the cavity is not large. Concave areas of the hand where pressure is not being maintained. The skin is assessed regularly to determine its readiness for a custom-made compression glove. When used too early on fragile skin. Gloves need to be replaced about every 2 months due to gradual loss of the material’s elasticity. Skin care and scar management The newly healed skin will initially be quite fragile and require protection from overzealous handling. The skin is gently massaged with a non-irritating oil or lotion several times each day to maintain suppleness and as an early desensitization exercise. Scar that is particularly raised and dense warrants use of silicone gel in conjunction with the garment even where garment compression is good (Katz. Psychological support Serious burns can result in permanent deformity. consultation with a psychologist or psychiatrist should be arranged. will require an insert. Restoration of MCP joint flexion will require flap coverage as a first-stage procedure and release of joints as a second-stage procedure. sometimes involving numerous procedures. the fit will need to be assessed regularly to ensure that pressure is being maintained. Figure 17. Where scar is particularly dense and unyielding. deeper areas can be ‘filled’ with ‘Silicone Elastomer’ moulds or thermoplastic splinting material. Wellmoulded splints also provide effective pressure and are worn over the garment and silicone gel sheeting. injury and sun exposure. To help reduce friction to fragile skin during glove application. Patients will need much encouragement during their rehabilitation which may last for many months.224 The Hand: Fundamentals of Therapy which can be incorporated into the MCP joint flexion splint. Reconstructive surgery.g. To know whether pressure therapy can cease. Pressure therapy will need to be maintained for many months as scar maturation can take from 6 to 24 months to occur. If staff observe that the patient is not coping. 55 to 60 degrees of flexion. The emotional.e. the patient can leave the garment off for several consecutive days and check for any deterioration in skin texture and/or colour. silicone gel is used in combination with the glove. smooth and supple in texture. 6.

29. (1993). Schwanholt. K. (1989). Surgery for adduction contracture of the thumb after burn. pollicization. 2045–60.. Acta Chir. W. Manual on the Management of the Burn Patient. 127–30. Mosby. In Rehabilitation of the Hand: Surgery and Therapy (J. Lister. Malick.. L. L. B. 13. a groin or free flap will be required prior to this procedure. 31. Sheridan. Greenhalgh. Mahler. DeLinde. G. I. If skin coverage is inadequate. M. Where skin coverage is adequate and skin is supple. B. Amputation Severe burn injuries can result in amputation deformities. G. Dmitriyev. eds) pp. (1999). (1994). Correction of this deformity requires the division of fascia and muscle. 45–8. Surg. A. Reconstr. A. N. 6. the web spaces can be deepened by a procedure that is basically an exaggerated version of the V-M-plasty. 1013–9. The alternative option is a toe-to-thumb transfer. A. V. Resurfacing with a skin graft or flap may be necessary. Stern. Churchill Livingstone. L. and Carr. Plast. M. G. Pederson. and Miles. G. (1992). Cosmetic Dermatol. however. 1989). M. Davis. Green.. (1987). P. Silastic gel sheeting is found to be effective in scar therapy. . eds). 406–11. E. (1982). D. Reconstruction of the burned thumb by metacarpal lengthening.) pp. I. American Burn Association Meeting. Hunter. and Schnebly. D. Burns. and Smith. (1992). Salter. Davis.. The acutely burned hand: management and outcome based on a ten-year experience with 1047 acute hand burns. some thumb metacarpal length can be gained through bone distraction techniques (Stern and MacMillan. Rivers. Baltimore. To restore some length to the thumb and/or fingers. References Achauer. involves fibrosis of the adductor muscle and the first dorsal interosseous muscle (Dmitriyev and Petrov. D. This process is known as phalangization. C. 89. 236–42. Staley. R. L. 14(1). Richard and M. Improved management of post-burn oedema in the upper extremity using a foam elevation wedge. (1995). Thumb function can be restored with transfer of remnant digits. 1267–94. (1987). L. In Green’s Operative Hand Surgery (D. Saffle. and Warden. J. Callahan. ed. P. A comparative study. Trauma. and MacMillan. T. 173–188.. S. J. R. 10. D. Solem. Burns... A. Benmeir. Remodeling of scar tissue in the burned hand.e. F. H.The burnt hand 225 contracture of the first web space. and Sowder. 32. The burned hand. Deformity of the nail bed Nail bed deformities resulting from digital burn contractures can be corrected with proximal flaps which will provide good protection during activity and overcome the problem of repeated tissue breakdown. Burn Care Rehabil. A comparison of full-thickness versus split-thickness autografts for the coverage of deep palm burns in the very young paediatric patient. i.. J. et al. J. L. 1983). Early free flap coverage of electrical and thermal burns. Hotchkiss and W. The burnt hand. (Abstract). Harmaville Rehabilitation Centre Educational Resource Division. Hurley. J. In Hand Injuries: A Therapeutic Approach (M. (1991). Churchill Livingstone. G. Treatment of the burned hand: early surgical treatment (1975–85) versus conservative treatment (1964–74). Y. J. Burn wound care. (1995). D. W. M. J. and Petrov. C. Chick. R. P. G. D. and Ahrenholz. J. eds) pp. E. Mackin and A. E. Katz... 38. Plast. B. In Burn Care and Rehabilitation: Principles and Practice (R. Ben Yakar. R.. (1983).

functional impairment. autonomic dysfunction. functional impairment. myofascial pain. Those referred to previously as ‘causalgia’ are now known as Type 2 – CRPS (Koman et al. Disorders which were previously referred to as ‘RSD’ are now known as Type 1 – CRPS. The term ‘chronic regional pain syndrome’ (CRPS) has therefore been adopted. causalgia (minor and major). Some of the earlier used terms include: algodystrophy.. shoulder-hand syndrome and sympathetically mediated pain. Classification The past 100 years have seen considerable change to pain nomenclature. These terms have been used under the umbrella of ‘reflex sympathetic dystrophy’. autonomic dysfunction.18 Chronic regional pain syndrome Introduction Pain. worsen or develop weeks (usually 3 to 4) following initial trauma. dystrophic changes without clinical peripheral nerve lesion/ injury. The new classification emphasizes clinical characteristics (Jaenig. Type 1 Reflex sympathetic dystrophy – pain. This abnormal postinjury response can result in central pain imprinting and have devastating effects on hand function (Koman et al. however. This chapter will deal with the management of the first two types. Type 2 Causalgia – pain. These conditions are then categorized further depending on whether they respond to sympathetic intervention. is a normal consequence of hand trauma.g. 1996). dystrophic changes with a diagnosable peripheral nerve injury. Workers in this field believe that there has been an overemphasis on the sympathetic nervous system and that the term ‘reflex sympathetic syndrome’ has been used too broadly (Merskey and Bogduk. i. . 18.e. the pain state will persist. In a small number of patients. like oedema. The next phase is the subacute phase and lasts for a further 3 months. The condition is considered to be in the chronic phase from the 6th month onward (Fig. 1995) and includes various subgroups. Clinical phases of chronic regional pain syndrome The first 3 months of CRPS represent the acute phase. Type 3 Other pain dysfunction. 1999).1). It serves a useful biological function and in most instances resolves uneventfully. pain is sympathetically maintained (SMP) or sympathetically independent of pain (SIP)... Sudeck’s atrophy. e. 1994).

particularly . The pain symptoms of CRPS are commonly exacerbated by cold and movement. these measures often worsen the oedema or frequently cannot be tolerated as they exacerbate pain. this applies particularly to the older patient or one with a complex injury. this is known as allodynia. Figure 18. Early recognition Chronic regional pain syndrome can be reversed successfully in the first two phases. Early recognition of CRPS and appropriate intervention are essential to ensure a successful treatment outcome. light touch or a movement of air over the hand. particularly on the dorsum of the interphalangeal joints. While this view is no longer held. it is important to remember that unremitting pain has major psychosocial consequences (Covington. 3. lack of skin creases over the joints and the sheen of the skin. 18. Autonomic dysfunction Most CRPS patients exhibit some degree of vasomotor dysfunction (Pollock et al. It was previously thought that certain personality types were at greater risk of developing CRPS. or ‘pins and needles’. Indeed. Loss of skin creases. Note the gross oedema. Holding the hand down in a dependent position also increases pain (as well as increasing swelling and causing discoloration). Stiffness When the joints of the hand are swollen and each attempt at movement results in pain. Patients commonly describe the affected area as having a ‘burning’ sensation. passive movement.228 The Hand: Fundamentals of Therapy Figure 18. 2. Stiffness and disuse that have become entrenched over many months cannot be reversed by conservative measures. Symptoms and signs 1. stiffness can rapidly ensue. can be another component of pain.g. Its presentation can vary from mild to marked and it tends to be unresponsive to conventional treatment methods such as massage and compression. is a common manifestation. Paraesthesia.2. Persisting oedema results in soft tissue fibrosis which impedes tendon glide and intrinsic muscle function.2). is commonly observed (Fig. Early recognition of this condition and prompt intervention are the key to a successful outcome. others experience throbbing or shooting sensations. Chronic regional pain syndrome of recent onset. may sweat profusely (hyperhidrosis) or be dry (anhidrosis). Pain The pain response associated with CRPS is frequently disproportionate to the inciting injury and/or surgery and is called hyperalgesia. 4. Periarticular thickening is another consequence of longstanding oedema. Some patients state that their hand ‘feels hot inside’. stiffness and disuse which have become entrenched over many months cannot be reversed with conservative means. 1993). Extreme sensitivity to innocuous stimuli. The affected hand will be ‘hot’ (vasodilation) or ‘cold’ (vasoconstriction) to the touch. however. Oedema Swelling is a common but not universal feature of CRPS. 1995).. e.1.

involve the whole hand and occasionally. 5. 2000). causing the nails to curve downward. mottling of the skin. the entire upper limb. Investigations that can help confirm the diagnosis include: 1. 4. red. The patient suddenly exhibits or reports signs or symptoms that have been previously absent. Hand oedema that worsens in the early evening and subsides by morning can also be an indicator. by overuse of the hand on the previous day. Treatment The patient with CRPS is generally managed best by a team approach. Carpal tunnel decompression where there can be injury to the palmar cutaneous branch of the median nerve. Distinct red areas are sometimes present over the dorsum of the index and middle finger MCP joints. blue or purple. when touching the face or hair. e. hair and bone.e. Injury to the dorsal branch of the ulnar nerve during procedures involving the distal ulna or from trauma to this area. Possible triggers of CRPS While CRPS can result from a trivial injury. 2. A positive response will indicate that pain is being sympathetically maintained and that the use of oral sympatholytic drugs is indicated. the average age is 45 years. 4. The ‘skin wrinkle test’ for the assessment of sympathetic function (Vasudevan et al.g. the metacarpal and phalangeal bones. and often has a mottled appearance. Palmar fasciectomy for Dupuytren’s disease (incidence of about 7 per cent in Australia). Decompression of the first dorsal compartment for de Quervain’s syndrome where there can be injury to the superficial branch of the radial nerve. 3. This syndrome can be confined to a single digit. In the early stages of the disease. The nails can become thickened and rigid and the hair may coarsen. 6. Bone scan. 3. 2. In advanced cases of CRPS. sensations of burning or heat.g. Patient presentation Whilst this condition can occur in patients ranging in age from the late teens to the elderly.g. The members of this team should include: the specialist. Diagnostic testing The diagnosis of CRPS is usually made on clinical findings. 2. thus giving a ‘pencil-pointing’ appearance. surgical procedures or irritation of specific nerves that result in a higher incidence of this condition. e. X-ray which will show osteoporosis after the 5th week (Bickerstaff et al.e. stiffness and swelling do not begin to subside after several weeks of hand therapy. They include: 1. Diagnostic blocks such as a stellate ganglion or somatic nerve block. there are certain injuries. Osteoporosis results from demineralization and becomes evident on X-rays at about the 5th week. Trophic changes These changes involve skin. the patient’s family .. The fat pads at the tips of the fingers atrophy. e. The skin frequently has a glossy appearance resulting from nutritional changes. osteoporosis is evident in the carpal bones. It can sometimes be difficult to distinguish the signs and symptoms of a CRPS from those that accompany any significant hand trauma. The therapist should suspect the onset of CRPS if: 1. 3. Distal radial fractures which frequently affect the median nerve and require prolonged cast immobilization.Chronic regional pain syndrome 229 The hand may also be discoloured. Digital amputations with neuroma formation. A patient who has not had nerve damage reports altered sensory perception. Women develop this condition three times more often than men. i. 1991). the patient will describe the texture as being ‘rough’ in comparison to the unaffected hand. osteoporosis is seen in the polar region of the long bones. i. 5. Flattening of the cuticle base and rugae pattern may be observed. excessive sweating or swelling that cannot be accounted for. This becomes more marked when the hand is dependent and often reverses dramatically when the hand is then elevated. There is a sudden increase in the above symptoms that cannot readily be explained. There is a statistical relationship to smoking. Symptoms of pain. nails.. 4.

Pharmacological intervention and invasive). the patient is warned that increased pain and swelling are a typical response for the first few days and generally settle. It is simple to execute.3). After several days. Most cases of CRPS will reverse quite quickly after suitable treatment strategies have been instituted. Other therapy measures When pain has begun to subside. the sessions are increased to 5 minutes. scrubbing can be performed on a tabletop. The patient assumes the quadruped position. The motion should be continued for 3 minutes and be performed three times daily. 18. The upgrading of the programme should be commensurate with the patient’s ability to cope. 18. a pain specialist (anaesthetist) and a hand therapist. Method The ‘compression’ exercise requires a scrubbing brush. the patient is loaned a unit for home use. The ‘compression’ component of the ‘stress-loading’ programme involves the patient assuming the quadruped position and scrubbing a smooth surface using a backward-forward motion with the elbow extended and the patient leaning over the arm. Where it is impractical or difficult for the patient to assume this position. rubber insulation tubing can be cut and taped over the handles of a disposable plastic bag. Figure 18. non-invasive and appropriately places some onus of care onto the patient. this is gradually increased to a 2. Hand therapy The hand therapist has frequent and close contact with the patient and is often the first to recognise the signs and symptoms of CRPS. The ‘traction’ component of the programme is achieved by carrying a lightly weighted bag whenever the patient is standing or walking. The scrubbing brush is held in the affected hand and the patient begins scrubbing a smooth surface such as plywood board using a backward-forward motion. This programme has been used for 30 years. surgery may be indicated. Hand therapy. three times a day. These measures are . Until pain. swelling and autonomic signs have abated. The therapy protocol will need to address the entire upper limb to avoid restriction of shoulder movement from secondary adhesive capsulitis. all other hand therapy treatment modalities are delayed. 3. and then to 7 minutes after a fortnight.5 kg weight (Fig.3. There are commonly three components to patient management: 1. the inclusion of a psychologist and rehabilitation consultant may be warranted. The tubing provides an enlarged. If the response to TENS is favourable. (non-invasive In a small number of patients. Prior to commencement of the programme. The patient should lean over the arm and maintain elbow extension (Fig. Psychological support. The ‘stress-loading’ programme comprises traction and compression exercises that provide stressful stimuli to the extremity without joint motion. This motion is initially performed for 3 minutes. 2. comfortable and slip-resistant ‘handle’.4). The initial weight in the bag is approximately 0.230 The Hand: Fundamentals of Therapy practitioner.5 kg. Where the condition is prolonged and is impacting on the patient’s coping mechanisms and affecting family/work dynamics. If the specialist favours a conservative approach to management. appropriate therapy measures to overcome residual oedema and stiffness are commenced. For ease of grasp. the patient will be started on transcutaneous nerve stimulation (TENS) and the active ‘stress-loading programme’ described by Watson and Carlson (1987).

The Opsite is applied to those areas of the hand which are most symptomatic (Fig. 18. Figure 18. Interphalangeal joint finger stiffness can be overcome by gently bandaging the hand into flexion with a wide crepe bandage and immersing the hand in warm water for 15-minute periods several times a day. Repeated active movement of the more proximal joints cannot be overemphasized. For ease of grasp. 2000). They should be worn for short periods initially.6). The ‘traction’ component of the programme involves carrying a lightly weighted bag whenever standing or walking. This combination of stretch and warmth is highly effective in increasing joint flexibility prior to active finger flexion exercises. It concluded that Opsite used on unbroken skin in diabetics was effective in relieving the pain of peripheral neuropathy. 15 to 30 minutes. A wrist that is comfortably supported is also less painful (Fig.4. Splinting The MCP joints are frequently stiff and may require a dynamic flexion splint. Pressure garments Pressure gloves or compression wraps for oedema are used cautiously as they frequently aggravate pain and/or swelling. 18. Opsite Flexifix Over the past 18 months. The wrist can be serially splinted using a volar plaster which is held in place with a crepe bandage. serial plaster splinting to restore extension is important to facilitate finger flexion. When passive exercise is commenced.Chronic regional pain syndrome 231 Figure 18. it is best performed by the patient rather than the therapist. introduced gradually and response to them is assessed to avoid exacerbation of the condition. insulation tubing is cut open and taped over the handles of a disposable plastic bag. The exercise regimen should be performed hourly and include all upper limb joints. If wrist stiffness is a problem. priority is given to regaining extension so that finger flexion can be optimized. the wearing time is increased.5. Exercise Exercise should commence with active rather than passive motion as the latter often provokes pain.e. . If there is no adverse response. The use of Opsite in this way follows from a study carried out by the King’s College Hospital in London (Foster et al. 1994).5). the author has been using Opsite Flexifix to help manage the causalgic pain that many CRPS patients experience (BoscheinenMorrin and Shannon. Exercise involving the fingers and thumb should be carried out in a sustained and systematic fashion with emphasis on stabilized interphalangeal joint exercises. Where wrist stiffness is a problem.. i.

Covington. Lidocaine. the patient is unable to engage in normal work and recreational activities and relationships with family and friends soon become strained. Tegretol. Adrenergic compounds – such as Catapress and Dibenzyline.. Regional intravenous sympathetic block The Hannington-Kiff blockade (1974) for sympathetic pain is a modification of the analgesic drug infusion described by Bier in 1908. the place of chemical or surgical sympathectomy is controversial. and Shannon. Anticonvulsants – e. J. Radiographic changes in algodystrophy of the hand. J. 47–52. D. J. using intravenous drugs such as guanethidine (Field et al. 16B. 6. Apart from the physical discomfort. Psychological issues in reflex sympathetic dystrophy. O’Doherty. These patients frequently become depressed if the condition persists for more than a few weeks. Surgery When the clinical signs and symptoms of CRPS have settled. Figure 18.. (1991). 1996).. The timeframe of management will vary from patient to patient. i. In Reflex Sympathetic Dystrophy: A . e. All surgical patients will require sympatholytic medication during and after surgery to avoid potential recurrence of their symptoms. 4.. 3. Aust. Functional activity The patient is encouraged to use the affected hand in appropriate normal daily activity. The following categories of drugs are used: 1. These blocks. D. R. Calcium channel blockers – such as Procardia and Norvasc which are arterial vasodilators. (1995). References Bickerstaff. The area of application is outlined. however. Occ.232 The Hand: Fundamentals of Therapy 2. Other patients may need to undergo release of secondary joint contractures. To help relieve the ‘burning’ sensations in this gentleman’s hands following bilateral open carpal tunnel decompression. Drugs are often used in combination with one another or with intravenous regional sympathetic blocks. Corticosteroids – e. a neuroma may require resection or the median nerve may require further decompression. Activity is carefully upgraded in accordance with the patient’s progress. Pharmacological treatment The pharmacological approach to managing CRPS is complex and under constant review (Czop et al. Membrane-stabilizing agents – e. Hand Surg. If this is the case. (2000). usually need to be repeated 3 to 5 times at 2 to 3 week intervals.g. and Kanis. For patients with an entrenched pain syndrome. Tofranil. E.g. Ther. Their therapeutic effect usually becomes apparent 2 to 3 days following infusion when hand therapy techniques can be employed with maximum efficacy. Sinequan. As with any drug. Opsite Flexifix was applied to the reddened areas of discomfort. J. prednisone. The ‘stress-loading’ programme can be scaled back as improvement is noted. J. Dilantin. C. Opsite Flexifix: an effective adjunct in the management of pain and hypersensitivity in the hand.6. 1993). P.g. Antidepressants – the most commonly used are the tricyclic group. referral to a psychologist or psychiatrist is indicated.. Guanethidine and reserpine are no longer available in the United States. (submitted for publication). Psychological implications Chronic regional pain syndrome is a distressing condition. 5. the programme should be reinstituted at the first sign that symptoms of CRPS may be recurring. A.e. surgery may be necessary to correct the neural or mechanical trigger of the pain syndrome. reserpine and bretylium tosylate.g. patients need to be carefully screened for suitability prior to prescription and then monitored for potential side effects. Boscheinen-Morrin.

. Therapist’s management of reflex sympathetic dystrophy. P. 6. J. Diagnosis and management of sympathetically maintained pain. H. C.. A. Poehling. Surg. K. Hand Surg. P. Pollock. H. and Dellon. (1987).. Tribuzi. IASP Press. R. (1994). Campbell. S. D. Ochoa. Management. eds) pp. B. S. Ramamurthy. 277–87. A. L. D. Patterns of microvascular response associated with reflex sympathetic dystrophy of the hand and wrist. 21A. Grundberg.. Koman.. and Edmonds. and Poehling. O. E.. Progress in Pain Research and Management. 12. (1990). et al. H. 87.. J. Hunter.. Koman. B. Reflex sympathetic dystrophy: a disease of medical understanding. 6 (W. Green. Mackin and A. 23.. Hand Surg. 8. Nukada. open questions. eds) pp.. Jaenig and M. Smith. R. Watson. K. G. 1.. In Green’s Operative Hand Surgery (D.. J. L. and Carlson. R. G. (1994). R. J. (1990). 757–64. Z. (1991). Reflex sympathetic dystrophy syndrome: consensus report of an ad hoc committee of the American Association for Hand Surgery on the definition of reflex sympathetic dystrophy. E. G. (1988). Descriptions of chronic pain syndromes and definitions of pain terms.. signs and differential diagnosis. A. Pain Res. (1994). L. 12. (1991). Prog. Monk. (W. In Reflex Sympathetic Dystrophy: A Reappraisal. and Nordyke. 72B. ed. 768–72. (1993).. Contemp. (1995). A. M. Jupiter. van Ru. Pain. J. Lippincott. Complex regional pain syndromes: symptoms. and Li. M. Hand Surg. J. and Kanis. S. Merritt. Hand Clin. Churchill Livingstone. A. 1376–84. Gelberman. Clin. Treatment of reflex sympathetic dystrophy of the hand with an active ‘stress loading’ program.. Aust. Reconstr. M. Melzack. (1993).. Pain Res. S. 76A. Z. (1995). Davis. Smith. Rauck. M. J. Bone Joint Surg. 1. C. V.. M. 12A. hypotheses.. L. (1975). (1994). R. Czop.. A. N. Prog. P. Pain dysfunction syndrome. Selig. 11. Reflex sympathetic dystrophy: treatment with long-acting intramuscular corticosteroids. 636–66. Mackinnon. Lewis.. M. J. W. N. Management. E. eds) pp. Smith. 18A. 57–9. 51–7. N. Orthopaedics. Surg. 18B. K. (1996).Janig and M. In Reflex Sympathetic Dystrophy: A Reappraisal. N. 1. (2000). McConville. Pain. K.. 357–61. Raja. (1996). C. Koman. M.. 40. A. 339–42. and Smith. 779–85. Duckworth. H. Prolonged relief of pain by brief. (1987).. Jaenig. eds) pp. The relationship between nerve entrapment versus neuroma complications and the misdiagnosis of de Quervain’s disease. Mullins.. Stanton-Hicks. G. C. A. N. G. IASP Press. (1995). P. Classification of chronic pain. 667–70. H.. Boas. Objective improvements in algodystrophy following regional intravenous guanethidine. R. Jr. and Bogduk. Reflex sympathetic dystrophy. (1992). IASP Press. T. Vol. Duncan. J.. Walsh. R. (1985). Jaenig and M. 233 Further reading Amadio. C. Progress in Pain Research and Management. Pederson. 847–52. E. E. transcutaneous somatic stimulation. Vol. T. A. et al. Complex regional pain syndrome: reflex sympathetic dystrophy and causalgia. 6 (W. D. In Concepts in Hand Rehabilitation (B. J. Orthop. and Koman. Blanchard.Chronic regional pain syndrome Reappraisal. J. Vasudevan. et al. Features of algodystrophy after Colles’ fracture. Sympathetic maintained pain (causalgia) associated with a demonstrable peripheral nerve lesion. (1996). Racz.) pp. P. 363–6. B. Intravenous regional sympatholysis: a double-blind comparison of guanethidine. 1–8.. 85–100. 39–43. 191–215. D.. Management.. intense. B. Stanley and S. 11. F. E. T. eds) F. StantonHicks. reserpine and normal saline. Callahan. H. J. Walsh. The puzzle of ‘reflex sympathetic dystrophy’: mechanisms. Bohm. M. Merskey.. L. C. The pharmacologic approach to the painful hand. B.. L. Progress in Pain Research and Management Vol. Pain Symp. Hotchkiss and W. Seiler. (1978). L. Pain relief by anti-depressants: possible modes of action. N. Treatment of upper extremity reflex sympathetic dystrophy with joint stiffness using sympatholytic Bier blocks and manipulation. In Rehabilitation of the Hand: Surgery and Therapy (J. L. C. R. The painful hand.. L. J. J. 15. H. T. Pain. J. Feinmann. T. Skin wrinkling for the assessment of sympathetic function in the limbs. P. Acta Neurochir. Stanton-Hicks. J. Transcutaneous electrical nerve stimulation in chronic pain after peripheral nerve injury.. Med. Field. and Taylor. 357–73. A. Smith.. Eaton. Foster. Dobyns. 5. 371–5. Atkins. 883–6. Hand Clin. Diab. eds) pp. . 79–92. Mackinnon.. and Atkins. (1992). Bone Joint Surg. and Zienowicz. R. W. 817–33. (1999). Mosby. A. M. L. T. 633–42. Saplys. 1489–96. In Operative Nerve Repair and Reconstruction (R... J. Plast. Hand Surg. 105–10. 70. Application of Opsite film: a new and effective treatment of painful diabetic neuropthy. J. 1–24.. J. G.

183 Bouquet osteosynthesis. 176–7 reconstruction. 178–80 psychological aspects. 225 classification. 147. 146. 228 Amputation. 220 claw deformity. 215–16 healing. 1–13 Axonotmesis. 222–4 nail bed deformities. 211. 4 Active short arc motion protocol. 178 postoperative therapy. 225 oedema control. 224–5 scar management. 91 Arm: dynamic rotation splint. 139 Arthroplasty. 130 Bone: grafts. 223 friction. 222 pathophysiology. 224 reconstruction. 88 injuries. 57 Ballottement test. 16 Annular pulleys. 188–93. 224 skin grafts. 59 Axons. 152 Arthrodesis. 168 Bandages. 222 . 66 Bower’s hemiresection interposition arthroplasty. 215 Abductor digiti minimi deformity. 220 hand therapy. 170 Assessment.Index A1–A5 pulleys. 200 Arthrolysis. 26. 127. 28 Anterior interosseus syndrome. 224 skin care. 146–7 ‘Alloderm’. 186 Age and fracture outcome. 180–1. 157. 168. 152. 222 Allodynia. 155–6 Arthritis. 78 Abdominal flaps. 18 Active range of motion. 11 aids. 186–8. 124 Bouvier’s manoeuvre. 221 depth. 225 chemical. 175–82. 220–1 electrical. 121–2 scans. 161. post-traumatic. 156 flaps. 219 pressure therapy. 49–50 Activities of daily living. 219–25 amputation. 22 Barton’s fracture-dislocation. 216 Burns. 146. 168 Bouchard’s nodes. 66 Active exercise. 21. 225 surgical technique. 175 complications. 72 rotation exercises. 222 complications. 224 psychological aspects. 212 muscle fibre length. 172 Brachial plexus: gliding exercises. 220 exercise. 87. 28 A2 pulley splitting for ulnar nerve palsy. 148 Bennett’s fracture. 199–200 Arthroscopy. 178 Angiogenesis.

227–8 presentation. 20 Capitate fractures. 220 Chronic regional pain syndrome. 83. 227–33 causes. 229 splinting. 144–5 Carpal tunnel syndrome. 163 Capitate–lunate instability pattern. 164–9 grading. 90 scar hypersensitivity. 222 CLIP. 28 Callotasis. 229 pressure garments. 157 Contact inhibition. 86. 89 open. 169 Coban wrap. 147. 146. 103 Crepe bandages. 207–8 vocational assessment. 232 vasomotor dysfunction. 88 surgical decompression. 86 nerve gliding exercises. 89 postoperative pillar pain. 92–4 postoperative nerve gliding exercises. 16 Corticosteroid injections. 95 scar management. 203–10 blood flow restoration. 208–9 splinting. 166 Carpal ligaments. 93 spontaneous resolution. 232 hand therapy. 231 stiffness. 186–7 arthroplasty. 228 Opsite Flexifix management. 94 . 232 osteoporosis. 181 Callus formation. 152 motor signs. 89 Carpometacarpal joint. 91 Cubital tunnel syndrome. 231 psychological aspects. 89 endoscopic. 48. 230–2 nail changes. 92. 86. 163–4 Carpal fractures. 195 Carpal dislocations. 196 C1–C3 pulleys. 18–19 Colles’ fracture. 209 wound management: closure. 87. 228 phases. 22 Cruciate pulleys. 28 Cubital tunnel percussion test. 232 exercises. 227 Chemical burns. 220 Buttonhole deformity.236 Index Burns – continued splinting. 228–9 skin changes. 222. 90 scar management. 195 Causalgia. 203 reconstruction. 87 presentation. 232 sympathetic block. 90 return to activities. 229 pain. 205 functional activity. 228 surgery. 228 signs and symptoms. 85–6 autonomic findings. 88–90 complications. 203 psychological aspects. 149 Complex hand injuries. 231. 204–5 oedema management. 118. 92–5 nerve gliding exercises. 230 Compression screws. 86–7 stages. 231 functional activity. 205 scar management. 77–8 Caput ulna syndrome. 88 postoperative exercises. 86 causes. 94 scar hypersensitivity. 75 Capener splint. 206–7 fracture management. 205 debridement. 152. 66. 85 splints. 123 Claw hand. 217 exercises. 204–5 Compression exercises. 92 surgical options. 157–63 Carpal instability. 169 Capsulodesis of metacarpophalangeal joint. 84–90 assessment. 229 diagnosis. 223–4 thermal. 120 Computed tomography. 228. 228–9 Clam-digger position. 147. 144 ulnar translocation. first: arthrodesis. 204 emergency free flaps. 206–9 infection prevention. 204 dressing. 232 reversal. 121 Camitz palmaris longus opponensplasty. 209 hand therapy. 188–9 Carpus. 229 drug therapy. 206 prognosis. 100–1. 229 oedema. 230.

181 Double crush syndrome. 18 passive. 102 corticosteroid injections. 220 Endoneurium. 113 skin closure. 17–18 active. 91 Elderly. 2–3 visual. 135–8 Distal interphalangeal joint: flexion range measurement. 152–3 on cast removal. 50–3. 44 Extensor indicis proprius opponensplasty. 45–54 I and II. 153–4 open reduction and internal fixation. Thumb Disk-Criminator. 107–8 surgery: complications. 2–3 tactile. 143. 146–7 therapy: during fixator immobilization. 127. 54 Exudates. 113 procedures. 16 Duchenne’s sign. 1–13 Examination: physical. 171–2. 169 osteoarthritis. 26. 198 postoperative management. 83. 9 Dislocation: carpal. 102 splinting.Index 237 Daily living. 110–11 scar management. 75 Extensor pollicis longus rupture following distal radial fracture. 152 external fixation. 169–70 fractures. 18 Extensor carpi radialis longus transfer. 103 differential diagnosis. 112–13 outcome. 57 Endotenon. 43–5 repair. 112 Dynamometer. 109 incisions. 213–14 . 83 Dressings. 107 presentation. 107–115 aetiology. 199 de Quervain’s disease. 147 classification. 150 outcome. 48–50. 109 postoperative exercises. 146–57 arthroscopy. 111–14 postoperative splints. effects of. 187 Distal radial fracture. 163–4 distal radioulnar joint. 100 Digit. 45–6. 27 Epicondylectomy. 102–4 aetiology. 57–8 Epitenon. 5 fusion. 110 Diabetes. 76–7 Extensor carpi ulnaris tendon: inflammation. 148 complications. 11 aids. 27 Epithelial cells. 2 Exercises. 153–6 Distal radioulnar joint. 111 wound care. 15–16 Evaluation. 103 surgery. 169–70 proximal interphalangeal joint. 111 contraindications. 15–16 Family involvement. 54 III and IV. 186 Darrach procedure. 148. 170 Extensor digitorum communis. 147–8 closed reduction: K-wire fixation. 109 indications. 107 defined. 204 Dermofasciectomy. 171–2 Distraction lengthening. see Finger. 169–72 dislocation. 93 Epineurium. 145. 150–2 immobilization. 54 V and VI. 103–4 Debridement. 43–56 anatomy. 102. 113–14 postoperative management. 151–2 during immobilization after closed reduction. 17 Fascial flaps. 102–3 presentation. 103 diagnostic test. 104 subluxation. 152 assessment. 54 VII. 46–8. 10–11 Elbow flexion test. 109 oedema management. 66 Dupuytren’s contracture. 46 zones. 99. 150 plaster immobilization. 152 Extensor tendon. 146–7 Electrical burns.

238

Index

Fasciectomy, 110 Fasciocutaneous flaps, 212–13 Fasciotomy, 110 Fibroblasts, 16, 29 Fibula, bone harvesting, 216 Finger: flexion range, 4 functions, 176 scissoring, 122 tip injuries, 177–8 ulnar drift, 195–6 web span measurement, 5 Finkelstein test, 102, 103 ‘Flare’ reaction, 112 Flexor carpi radialis transfer, 79 Flexor carpi ulnaris: tendovaginitis, 104 transfer, 79, 80–1 Flexor digitorum superficialis exercise, 34 Flexor pollicis longus repair, 38 Flexor pulley advancement, 78 Flexor retinaculum, 84 Flexor tendon, 27–42 anatomy, 27–8 blood supply, 28, 29 healing, 29 nutrition, 28–9 pulleys, 27–8 reconstruction, 40–1 repair, 29–40, 198–9 active motion protocols following, 32–3 contraindications, 29 early mobilization following, 31 exercises, 33–4, 35–8 oedema management, 34 postoperative management, 31–8 scar management, 35 splints, 33 technique, 29–30 timing, 29 zones, 30–1 sheath, 27 repair, 29 synovial fluid, 28–9 Forearm: dynamic rotation splint, 156 flaps, 212 rotation exercises, 155–6 Fracture, 117–32, 205 assessment, 117 callus formation, 121 carpal, 157–63 classification, 117–18 complications, 120–1

fixation methods, 119–20 external, 120 intramedullary, 120 screws, 120 wires, 119–20 healing, 121–2 in elderly, 127, 146–7 metacarpal, 122–5 open reduction and internal fixation, 119–20 phalangeal: distal, 129–30 proximal and middle, 125–9 plates, 120 position of safe immobilization, 118 proximal interphalangeal joint, 138–9 radioulnar joint, distal, 169 radius, distal, 146–57 stable, 118 thumb, 130–1 unstable, 119–20 Free tissue transfer, 211–18 advantages, 212 free flap choice, 212–17 in emergency, 217 postoperative care, 214, 216, 217 problems, 212 Friction burns, 220 Froment’s sign, 66 Functional assessment, 11 Gnosis tests, 9–10 Goniometers, 5–6 Grip strength, 10–11 Groin flaps, 211, 212 Guyon’s space, 84 Haemachromatosis, 183 Haldex gauge, 4 Hamate fractures, 162–3 Hand: bathing, 154 prostheses, 181–2 sensory innervation, 7 ulnar border hyperaesthesia, 66 Handitube, 26 Hannington–Kiff blockade, 232 Healing process, 15–17, 29, 73, 121–2 Heberden’s nodes, 183 Herbert ceramic ulnar head, 172 History taking, 1 Hitch-hiker’s test, 102 Hormonal changes, 83, 86

Index

239

Hulten’s variance, 143–4 Hydrogen fluoride burns, 220 Hyperalgesia, 228 Hyperhidrosis, 3 Iliac crest, bone harvesting, 216 Imbibition, 28 Index finger: abduction, tendon transfer for, 79 function, 176 Inflammatory disease, 99, see also Rheumatoid arthritis Inflammatory phase of healing, 15–16, 29, 121 Innervation density tests, 8–9 Interossei: dorsal, 44 volar, 44 Interphalangeal joint, see Distal interphalangeal joint; Proximal interphalangeal joint Intrinsic plus position, 118, 123 Ischaemia in compression neuropathies, 86 Jamar dynamometer, 10–11 Joint stiffness, 3, 139 Kienboeck’s disease, 161–2 Kirschner wires (K-wires), 119 Kleinert regimen, 31 Lag screws, 120 Little finger function, 176 Lumbricals, 44 Lunate fractures, 161–2 Lunotriquetral dissociation, 168–9 Lycra, 21, 22 Magnetic resonance imaging, 146, 157, 161, 170 Mallet finger, 46–8 Mallet thumb, 54 Mannerfelt’s lesion, 198 Manual muscle testing, 11 Massage, 154, 208 Medial epicondylectomy, 93 Median nerve: branches, 84–5 compression, 84–91 gliding exercises, 87 lesion, 64–5 opponensplasty for, 73–5 sensory retraining after, 68–9 sensory innervation, 7

Metacarpal: distraction lengthening, 181 fracture, 122–5 Metacarpophalangeal joint: capsulodesis, 77–8 contracture, 108 dorsal hood, 43 dynamic flexion splinting, 193 implant arthroplasty, 192–3 thumb, 140 volar subluxation/dislocation, 195–6 Microenvironmental dressings, 16 Microfoam, 21, 22 Midcarpal instability, 169 Midcarpal joint, 143 Middle finger function, 176 Minimal active muscle-tendon tension, 53 Moberg pick-up test, 9–10 Monkey hand, 64 Monofilaments, 7–8 Motor fibres, 57 Multiple crush syndrome, 83 Muscle: atrophy, 60 fibre length, 72 fibrosis, 60 flaps, 214–15 functional, 216–17 manual testing, 11 Myelin sheaths, 57 Myofibroblasts, 16 Nail bed deformities, 225 Nail changes: chronic regional pain syndrome, 229 nerve injury, 60 Neoprene, 21, 22–3 Nerve: anatomy, 57–8 axonal transport, 57 axonotmesis, 59 blood supply, 58–9 compression, 83–98 causes, 83–4 clinical features, 84 diagnosis, 84 conduction velocity, 6, 8 degeneration, 60 fibres, 57 gliding exercises, 87, 88, 92, 93, 94, 96 injury types, 59–60 lesions, see specific nerves median, see Median nerve

240

Index

Nerve – continued motor fibres, 57 myelin sheaths, 57 neurapraxia, 59 neurotmesis, 59–60 nodes of Ranvier, 57 radial, see Radial nerve regeneration, 60, 61 monitoring, 10 repair, 60–4 epineurial, 61 fascicular/perineurial, 61 healing, 61 patient education, 62 postoperative management, 61–4 scar management, 62 sensory retraining after, 68–9 sensory fibres, 57 sutures, 61 ulnar, see Ulnar nerve ‘Neuflex’ prosthesis, 188 Neurapraxia, 59 Neurotmesis, 59–60 Ninhydrin sweat test, 10 ‘No man’s land’, 30 Nodes of Ranvier, 57 Nodules, 3 Obesity, 86 Oblique retinacular ligament, 44–5 Occupation, 86 Oedema: acute/chronic differentiation, 3 Coban wrap, 18–19 fluctuation, 6 management, 16, 18–19 measurement, 6 transudate, 15 Oil massage, 154, 208 Open wound technique, 111 Opponensplasty, median nerve palsy, 73–5 Camitz palmaris longus, 75 extensor indicis proprius, 75 superficialis of ring finger, 73–5 Opsite Flexifix, 24–5, 231, 232 Osteoarthritis, 171–2, 183–93 distal radioulnar joint, 171–2 drug therapy, 184 functional assessment, 186 hand therapy, 184–5 pathogenesis, 183–4 signs and symptoms, 171, 184 surgery, 171–2, 186–93

Osteoporosis, 147, 229 Osteotomy, wedge/rotation, 123–4 Pain, 15 and inflammation, 15 assessment, 3–4 -reducing dressings, 16, 19, 24–5 scales, 4 Palmar aponeurosis pulley, 27 Palmar fasciitis, 152 Palpation, 3 Parascapular skin flaps, 212 Paratenon, 27 Passive exercise, 18 Passive range of motion, 4 Patient education, 62, 203 Pedicled reconstruction, 211 Perilunate dislocation, 163–4 Perineurium, 57 Phagocytosis, 15 Phalanges: distraction lengthening, 181 fractures: distal, 129–30 proximal and middle, 125–9 Phalangization, 225 Phalen’s test, 85–6 Physical examination, 2–3 Pick-up test, 9–10 Pillar pain, 90 Pilon fracture, 138–9 Pinch grip, 11 Pisiform, 143 Place and hold exercises, 36 Point localization, 9 Position of function, 205 Position of safe immobilization, 118, 123, 222 Posterior interosseus nerve syndrome, 95 Power grip, 10–11 Pressure therapy, 22, 224, 231 Pronator syndrome, 90–1 Prostheses, 181–2 Proximal interphalangeal joint: anatomy, 133–4 assessment, 134–5 collateral ligaments, 133–4 contracture, 108–9 dislocation, 135–8 flexion deformity prevention, 19, 34–5, 125, 136, 223 fractures, 138–9 fusion, 187 implant arthroplasty, 189–92

Index

241

signs and symptoms of injury, 134 surgery, 139–40 volar plate, 134 Psychological aspects, 11–12, 176–7, 203, 224, 228, 232 Pulleys, 27–8 advancement, 78 Radial forearm flaps, 212 Radial fracture, see Distal radial fracture Radial nerve: compression, 95–6 superficial, 96 gliding exercises, 96 lesion, 66–8, 79 splinting, 67–8 tendon transfer, 79–81 sensory innervation, 7 Radial tunnel syndrome, 95–6 Radiocarpal joint, 143 Radiographs, 117, 135, 146, 147, 157, 161, 165–6, 168, 170 Radioulnar joint, distal, 143, 145, 169–72 dislocation, 169–70 fractures, 169 osteoarthritis, 171–2 Radius: bone harvesting, 216 fracture, see Distal radial fracture tilt and inclination, 143 Range of motion, 4–6 active, 4 passive, 4 torque, 4 Reconstruction, 40–1, 180–1, 205, 224–5, see also Free tissue transfer Reflex sympathetic dystrophy, 227 Regenerative phase of healing, 16 Remodelling, 16–17, 29, 122 splints, 20 Retinacular ligaments, 44–5 Rheumatoid arthritis, 193–200 deformities, 195–7 drug therapy, 194 hand therapy, 194–5 phases, 194 surgery, 197–200 arthrodesis, 200 arthroplasty 199–200 Darrach procedure, 199 soft tissue reconstruction, 200 tendon repair/transfer, 198–9 tenosynovectomy/synovectomy, 197–8

Ring finger: function, 176 superficialis opponensplasty, 73–5 Rolando’s fracture, 130–1 Sauve–Kapandji procedure, 172 Scaphoid, 144 blood supply, 157 fractures, 157–60 diagnosis, 157 open reduction and internal fixation, 159–60 presentation, 157 salvage procedures, 160 short arm cast, 159 Watson scaphoid shift test, 165 Scapholunate advanced collapse deformity, 164 Scapholunate dissociation, 164–8 assessment, 165–7 conservative treatment, 167 presentation, 165 late with arthritis, 167–8 radiology, 165–6 surgery, 167 Scapholunate ligament, 145 Scapular skin flaps, 212 Scar: management: Coban wrap, 19 silicone gel, 23–4 palpation, 3 remodelling, 16–17 Scissoring of digits, 122 Semmes–Weinstein monofilaments, 7–8 Sensibility testing, 6–10 Sensory fibres, 57 lesions, 60 Sensory retraining, 68–9 Serial casting, 19 ‘Shear’ test, 168 Silicone gel, 23–4 Simian hand, 64 Skeletal reconstruction, 215–16 Skier’s thumb, 140–1 Skin: denervation, 60, 64 dryness, 3 nodules, 3 palpation, 3 sweating, 3 swelling, see Oedema tactile adhesion reduction, 60 temperature, 3, 60 thickening, 3 wrinkle test, 10, 229

71 prerequisites. 54 metacarpophalangeal joint. 72 tendon choice. 170 Triangular ligament. see Extensor tendon flexor. 47. 27 extensor. 67 . 197–8 Tenosynovitis. 19 soft splints. see Tactile headings Traction. 213. 197–8 Synovial sheath. 172 Sweat test. 225 web space flaps. 99. 196–7 extensor injuries. 71 single/dual. 54–5 fractures. 230 Trans-scaphoid perilunate dislocation. 21–3 Soft tissue: palpation. 147. 60 Temporoparietal fascia. 188–9 deformities. 100–1. 3 Swelling. 196 Swanson silicone caps. 20–1 remodelling splints. 65. 71 healing. see under Extensor tendon. 10 Sweating. 27 glide exercises. Flexor tendon stress effects. 175–6 joint injuries. 3.242 Index SLAC wrist. 19 principles. 25–6. 232 Synovectomy. 44 Trapezium excision. 180–1. 230 Transcutaneous electrical nerve stimulation (TENS). 145 tears. 77. 140–1 mallet thumb. 213. 73 pathway. 165 Therapists. carpal fractures. 27 transfer. 212–13 Tomography. 5 Tinel’s sign. 103 Stiffness. 78–9 carpometacarpal joint: arthrodesis. see Flexor tendon function. 198–9 contraindications. 38–40 Tenosynovectomy. 164. 27 reconstruction. 200 Splinting. 214 Tendon: adherence. 9–10 Temperature of skin. 157 Torque range of motion. 20 serial. 45 Trick movements. 130–1 function. 188–9 Treatment tools. 79 Swan-neck deformity. see Oedema Sympathetic block. 169 Superficialis: opponensplasty. 66. 73 junctions. 224–5 web span measurement. 223. 147 Soft splints. 140 reconstruction using toe. 5 Tenodesis. 71–2 tension. 27 epitenon. 220 Thumb: adduction restoration. 27 Tactile adhesion reduction. 4 Touch. 3 reconstruction/intrinsic release. 99–104 endotenon. 162–3 Steroid injections. 86. 140–1 ulnar nerve palsy. 225 skier’s thumb. 84. 73–5 transfer. 197 Terry Thomas sign. 60 Tactile examination. 99 paratenon. 78–9 web contractures. 36–7 Tenolysis. 146. 72 preoperative preparation. 2–3 Tactile gnosis tests. 71–82. 85 Transverse retinacular ligament. 19–23 dynamic/static. 186–7 arthroplasty. static. 163–4 Transudate oedema. 15 Transverse carpal ligament. 120 exercises. 10. 155 constriction. 17 Thermal burns. 72–3 Tenodesis effect. 230 Sugar tong splint. 180–1. 21–3 Sports. 17–26 Triangular fibrocartilage complex. 78 Tenodesis manoeuvre. 40–1 repair. 139 Stress-loading programme. 91 Toe: transplantation. 3. 164 Smith’s fracture. 39 inflammation.

2 Vocational rehabilitation. 165 Web space.Index 243 Trigger finger/thumb. 209 Volar plate. 8–9 Ulnar carpal impingement. 164. 66. 5 Wedge osteotomy. 212–13 Web span measurement. 92. 157. 95 Ulnar variance. 85 Wallerian degeneration. 62 osteoarthritis. 76–8 thumb adduction restoration. 78–9 sensory innervation. 225 flaps. 195 prosthesis. 94 lesion. contractures. 6 Waking numbness. 7 Ulnar tunnel syndrome. 147. 216 Volumeter. 75 tendon transfer. 10. 195 drop. 123–4 Wound: debridement. 195–6 Volkmann’s ischaemic contracture. 96 Washington regimen. 100–1 presentation. 152 assessment. 170 . 146 collapse deformity. 143–4 Vincular blood supply. 165–6. 145–6 nerve injuries. 168. 15–17 open wound technique. 32 Watson scaphoid shift test. 143–5 arthroscopy. 168 Ulnar collateral ligament injury. 66–7 flexion test. 223. 99–102 corticosteroid injections. 160–1 Two-point discrimination/localization. 85–6 fusion. 91–2 presentation. 101–2 Triquetro–hamate–capitate ligament laxity. 187 splinting: dynamic. 155 serial. 93. 100 splinting. 29 Visual examination. 204 dressings. 187–8 movements. 16 healing. 154 X-rays. 91–5 assessment. 135. 101 surgery. 146. 134 suluxation/dislocation. 212 Ulnar head: dorsal subluxation. 91 gliding exercises. 146. 154–5 support. 143–73 anatomy. 229 Wrist. 170–1 Ulnar carpal instability. 117. 86–7. 169 Triquetrum fractures. 60 Wartenburg syndrome. 111 Wrinkle test. 172 Ulnar nerve: compression. 140–1 Ulnar forearm flaps. 224–5 deepening. 28. 161.

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