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Hand Therapy

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SECTION VII • New Directions

43
Hand therapy
Wendy Moore, Minnie Mau, and Brittany N. Garcia

Access video content for this chapter online at Elsevier eBooks+

SYNOPSIS domains of focus include body functions and structures; activ-

ity and performance; and environmental influences. For both
Flexor tendon injuries treated with optimal repair techniques may benefit the surgeon and hand therapist, the use of occupation-based
from an early active motion regimen utilizing short arc active flexion and impairment-based assessments encompass these areas
exercises initiated within the first postoperative week. of focus and serve as the foundation for the informed deci-
The use of a relative motion extension orthosis has become the stan- sion-making that guides treatment.
dard of care for the treatment of extensor tendon repairs with evidence
to support earlier functional hand use and return to work. Occupation-based assessments
Fracture management has shifted toward early mobilization during
the initial phases of fracture healing using custom orthoses and safe Occupation-based assessments are self-reported health ques-
parameters of motion. tionnaires that describe “occupations” as the tasks people
Sensory and motor re-education following nerve injury are directed at need to do, want to do, and are expected to do. A survey of
strengthening and reinforcing the new and altered neural pathways in hand therapists3 identified practice trends of assessments most
the sensory and motor cortex. commonly used in hand therapy settings. The most frequently
A replanted digit will be considered viable after the first 7–10 days after used occupation-based assessments included activities of daily
surgery. The therapist must consider the nature of the injury, fracture living (ADL) assessments, described as an informal interview
fixation, quality of tendon and nerve repair, soft tissue, and vascular at the time of the evaluation, and the Quick Disability of Arm,
involvement to manage these complex injuries safely and successfully. Shoulder, Hand Questionnaire4 (QuickDASH). Other assess-
ments commonly used by hand therapists include the Patient
Rated Wrist and Hand Evaluation4 (PRWHE) and the Patient
Specific Functional Scale5 (PSFS).

Patient evaluation Impairment-based assessments

As defined by the American Society of Hand Therapists Impairments are defined as dysfunction or significant struc-
(ASHT),1 the practice of hand therapy embodies the art and tural abnormality within a specific body part or system.5
science of evaluating and treating injuries and conditions Evaluation of biomedical impairments include the evaluation
of the upper extremity through therapeutic interventions to of pain, edema, wound, vascularity, sensation, range of motion,
help return a person to their highest level of function. A hand and strength. Although impairment does not correspond pre-
therapist evaluates and treats any condition related to the cisely with disability, decreasing impairment can be helpful in
upper extremity, optimally, in collaboration with the treating decreasing disability.6 In order to treat each of these impair-
surgeon. This chapter aims to provide an overview to upper ment domains, one must understand how they are evaluated.
extremity surgeons of the approaches used by hand therapists Pain is frequently rated on four types of scales: numeri-
for the treatment of patients with upper extremity nerve, mus- cal scales, visual analog scales, verbal rating scales, and the
culotendinous, vascular, ligamentous, and skeletal conditions. FACES pain rating scale. Although designed as a measure of
The International Classification of Functioning, Disability intensity, these pain ratings reflect more than just the magni-
and Health (ICF)2 uses a conceptual model for evaluating the tude of pain and are likely influenced by the patient’s pain
impact of all health states on the individual. These interrelated beliefs, catastrophizing and/or pain interference.7

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984 SECTION VII CHAPTER 43 • Hand therapy

The criterion standard for measuring hand and wrist Range of motion (ROM) is frequently used to assist in
edema is water volumetry. Although this technique is both assessing the presence or absence of pathology, to establish
reliable and valid, it is time consuming and can be difficult to a baseline for treatment planning, evaluate the effects of
perform. The figure-of-eight technique has gained popularity therapeutic interventions, and as an outcome measure for
due to its ease of use and excellent intra- and inter-rater reli- research.13 The ASHT recommends optimal standard testing
ability.8 This method, modeled after the method described by positions and documentation criteria to create consistency
Esterson and colleagues,9 involves the use of a tape measure among practitioners.14 Established methods of measurement
wrapped around specific landmarks on the hand and wrist in of hand ROM include visual estimation, goniometry, and com-
order to assess size and compares this value to the patient’s posite finger flexion to distal palmar crease (DPC). Given that
contralateral or non-involved extremity (Fig. 43.1). visual estimation has been shown to be less reliable, goniom-
Sensation testing is used to determine the status and degree etry has become an essential component to any musculoskel-
of potential injury to each of the three peripheral nerves in the etal evaluation.15 Composite finger flexion may also be used if
hand. The Semmes Weinstein Monofilament Test10 is a widely multiple joints are involved (Fig. 43.2). Standard goniometry
used threshold test performed with the examiner applying and the measurement of composite finger flexion have been
graded monofilaments to the involved dermatome until one shown to have good inter-rater reliability.16
is detected by the patient. Strauch’s Ten Test11 was developed Grip strength has been widely used as an indicator for
as a more rapid and simple evaluation tool that requires no overall muscle strength and as a measure of hand function.17
instrumentation and is administered by the examiner lightly The ASHT recommends the use of the Jamar dynamometer
touching the test area and simultaneously comparing that in the second handle position be used when evaluating grip
with a known unaffected area. The test is based on a 10-point strength and further clarifies that patients should be seated
numeric scale stimulus rating in relation to normal sensitiv- with the shoulder adducted and in neutral rotation, the elbow
ity and has been shown to have both good inter- and intra- flexed to 90° and the forearm and wrist in neutral position.18
rater reliability.12 The two-point discrimination (2PD)10 test is Established normative data for grip strength in healthy adults
another widely used assessment of hand sensibility. It may in the United States demonstrate that the dominant hand
be used as a quick test of normal versus abnormal sensibility, possesses a 10% greater grip strength than the non-dominant
though it has been found to lack sensitivity for early detection hand in healthy subjects when the right-hand is dominant.19,20
of nerve entrapment. Dynamometer measurements assist therapists and surgeons
with clinical decision-making, particularly in the realm of
appropriate timing for return to activities such as weight-bear-
ing, return to work, and return to sport.

Figure 43.1 The figure-of-eight measurement technique for assessing edema

is performed using a tape measure that is started at the base of the scaphoid and Figure 43.2 To measure composite finger flexion, the goniometer is placed
wrapped ulnar across the distal wrist crease, distal and oblique across the dorsum of perpendicular to the distal palmar crease (DPC). The patient is asked to bring their
the hand toward the second metacarpal, along the palmar digital crease in an ulnar fingers into a full fist position attempting to touch the palm of their hand. Each digit
direction to the fifth digit and back across the dorsum of the hand to the starting is measured as the distance from finger pulp to DPC with 0 indicating full composite
point. (Courtesy of Wendy Moore, OTR/L, CHT.) flexion of the digit. (Courtesy of Wendy Moore, OTR/L, CHT.)

Clinical tips

Assessment
• Collaboration between the surgeon and therapist is imper-
ative for maximizing patient outcomes in the treatment of
upper extremity injuries and conditions.
• Occupation and impairment-based outcome measures are
used at the time of evaluation and throughout treatment to
1
evaluate the impact of therapeutic interventions and provide
objective comparisons for determining progress. 2

• Occupation-based assessments, such as the QuickDASH, 3

evaluate the ability of a patient to perform their meaningful
and purposeful activities. Impairment-based measures, such 4 T1
as pain, ROM, and grip strength, identify an abnormality in a
specific body part or system. 5 T2
• There is limited correlation between impairment and disabil-
ity. Understanding of the patient’s goals and collaboration
T3
between the patient, therapist, and surgeon is crucial for
maximizing patient outcomes.
6
T4

Rehabilitation following tendon injury 7 T5

Extensor tendon injury

Zone I/II
Rehabilitation following extensor tendon injury is largely Figure 43.3 Extensor tendon zones of the digits and thumb. (Reproduced
guided by the zone of injury and the anatomy and biomech- from Kleinert HE, Schepel S, Gill T. Flexor tendon injuries. Surg Clin North Am.
anics of the extensor mechanism in each zone (Fig. 43.3). A 1981;61:267–286.)
zone I injury, referred to as a mallet injury, presents as the
inability to extend the distal interphalangeal (DIP) joint of the
finger due to detachment of the terminal tendon. This injury
can be the result of soft-tissue rupture or avulsion of the exten-
sor tendon along with a small fragment of bone. Terminal ten-
don excursion during full DIP joint motion is between 1 and
2 mm for all digits. Due to this small amount of excursion, as
little as 1 mm of terminal tendon lengthening can result in 25°
of DIP joint extension lag which may correlate with clinical
disability.21
Although both surgical and non-surgical treatment of
mallet finger injuries can lead to excellent clinical outcomes,
immobilization is the treatment of choice in uncomplicated
cases.22,23 Patients are placed in an orthosis that holds the DIP
joint in neutral or slight hyperextension continuously for 6–8
weeks, with the proximal interphalangeal (PIP) joint free to
prevent stiffness (Fig. 43.4). After that time, patients may be
advised to continue with nighttime immobilization for up to
4 additional weeks.24 Many studies have compared various
orthoses for the management of mallet injuries though there
has been no conclusive evidence to support one type over
another. In a study comparing three different orthoses – stack,
dorsal aluminum, and custom thermoplastic – no difference
in extensor lag was identified based on orthosis type, how-
ever, the custom orthosis was less likely to result in compli-
cations.25 Although the type of orthosis may not significantly
impact lag difference, patient compliance in wearing the Figure 43.4 A zone I injury, known as a mallet injury, is typically treated with
orthosis has been shown to affect outcome in the treatment immobilization in a static DIP joint extension orthosis maintained full time for 6–8
of these injuries.26 weeks. (Courtesy of Wendy Moore, OTR/L, CHT.)

Zone III/IV
Extensor zone III/IV injuries have been reported to result
in the highest percentage of fair to poor outcomes.27 In zone
III injuries, compromise of the central slip often results in a
boutonnière deformity. These injuries can be difficult to diag-
nose as patients may initially present with full ROM if some
amount of the extensor hood is still intact. It is not until the
lumbricals attenuate that the PIP joint may fall into a flexion
deformity, hyperextending the DIP joint.28 Once the deformity
presents, it can be difficult to treat. Historically, when treated
nonoperatively patients are immobilized for 3–6 weeks with
the PIP joint in extension, the DIP joint, metacarpophalangeal
(MCP) joint, and wrist joints free. This may be followed by 6
more weeks of nighttime extension immobilization.29 Patients
are instructed in active flexion exercises of the DIP joint while
holding the PIP joint in extension to promote retraction of the
lateral bands dorsally from a volarly subluxed position.
Although immobilization is widely used, both Evans and
Merritt advocate for early motion orthosis-based therapy in
the treatment of chronic boutonnière injuries and those under-
going acute repair. Evans et al.30 found that patients treated
with an early active short arc motion protocol had better
outcomes than those treated with immobilization. This pro-
tocol, initiated within 48 hours after surgical repair, uses a
template orthosis that allows PIP joint flexion up to 30° and
DIP joint flexion up to 25°. The patient is placed in full PIP Figure 43.5 A static extension orthosis immobilizing the wrist and metacarpal
joint extension with the DIP joint free at all other times. While phalangeal joints while allowing the interphalangeal joints to be free may prevent
this short arc motion protocol continues to be widely used, it finger stiffness. (Courtesy of Wendy Moore, OTR/L, CHT.)
requires strict patient compliance and a long course of ther-
apy. Merritt28 advocates for use of the relative motion flexion surgery, and the RME orthosis discontinued by 6 weeks post
(RMF) orthosis to treat boutonnière deformities following sur- surgery (Video 43.1 ) (Fig. 43.6).
gical repair or closed treatment. The injured digit is placed in Traditionally, the wrist orthosis was considered essential
15–20° greater MCP joint flexion than their neighboring digits to protect repairs in this zone; however, more recent evidence
for 6 weeks and otherwise permits full active range of motion has challenged the need for wrist immobilization and has sup-
(AROM) and functional hand use. For a fixed-chronic bouton- ported the use of the RME orthosis alone. A survey by Hirth
nière, serial casting is first implemented in order to obtain as et al. has suggested that it may be possible for zone V and VI
much PIP extension as possible (at least −20°) and is followed injuries to be managed safely using the RME orthosis only.
with the RMF orthosis for 12 weeks.28,30 Their paper reviewed four studies involving zone V and VI
extensor tendon repairs in which the RME orthosis was the only
orthosis used postoperatively and resulted in good–excellent
Zone V–VII ROM outcomes without tendon ruptures. Surgeon preference,
Zone V injuries, which involve the sagittal bands, commonly quality of repair and patient factors should be considered in
occur from a human bite, an open laceration, or a closed rup- determining if the wrist component is necessary for repairs in
ture. When treated with immobilization, the digits are posi- this zone.
tioned with the MCP joint in static extension and IP joints free
(Fig. 43.5). While conventional postoperative management in
this zone has been to immobilize for 4–6 weeks, early active
Thumb
motion has become the standard of care across many institu- The extensor pollicis longus (EPL) tendon is prone to rupture
tions to limit the loss of flexion that often results from pro- over the distal end of the radius secondary to a distal radius
longed immobilization in extension. fracture, rheumatoid arthritis, direct injury or chronic attri-
In a recent international survey, hand therapists selected tion.32 Rupture of this tendon may be missed at time of evalua-
the relative motion extension (RME) orthosis, commonly tion. If the EPL tendon is ruptured, the abductor pollicis longus
referred to as a yoke splint, as the “most used” approach for (APL), abductor pollicis brevis (APB), and flexor pollicis brevis
postoperative management of zones V and VI extensor ten- (FPB) as well as extensor pollicis brevis (EPB) are all capable of
don repairs.31 The RME orthosis is described as a part of the producing weak extension of the IP joint, leading a clinician to
Immediate Controlled Active Motion (ICAM) program, which mistakenly conclude that the EPL is intact. To more accurately
provides a timeline for managing orthosis wear for zone IV– isolate the EPL tendon, the patient is asked to place their palm
VII injuries. Initially the patient is placed in the RME orthosis flat on the table and attempt to extend the thumb up off the
continuously, with or without a wrist orthosis, and instructed table (retropulsion). The examiner can palpate and sometimes
to move through full ROM within the confines of the orthosis. visualize the EPL tendon ulnar to the EPB tendon and confirm
If used, the wrist orthosis can be discontinued at 3 weeks post that the IP joint is being extended. The examiner can then ask

Figure 43.6 A relative motion extension orthosis may be

used alone (A) or with a wrist orthosis (B) for the treatment
of zone V–VII extensor tendon injuries. (Courtesy of Wendy
A B
Moore, OTR/L, CHT.)

the patient to resist IP joint extension. Of note, patients may Flexor tendon injury
develop a pseudotendon in the setting of an attritional EPL rup-
ture which may also contribute to some isolated IP joint exten- The study of flexor tendon injury continues to be an area of
sion, though this is frequently weaker when compared to the robust academic and clinical research as advancements in sur-
contralateral side. When identified in the acute setting, these gical repair guide advancements in rehabilitation. Following
injuries may be treated with primary repair. In a more chronic a strong multistrand repair, the selection of an appropriate
setting, these injuries are often treated with tendon grafting or rehabilitation regimen has the potential to minimize extrin-
tendon transfers, with the most common being the transfer of sic adhesion formation, optimize tendon glide, and maximize
the extensor indicis proprius (EIP) tendon to the EPL stump. motion and function of the hand.
While there is some literature supporting early active motion An ideal postoperative therapy program would create the
following these tendon transfers, patients are typically immo- greatest amount of tendon excursion with the lowest force on
bilized for 3-4 weeks in a forearm-based thumb spica orthosis, the healing tendon to minimize adhesion formation, gapping,
with the wrist in neutral and the thumb in abduction and exten- and rupture. With these goals in mind, current flexor tendon
sion.33 Gentle progressive active motion is started after this time. rehabilitation management should take into consideration the
timing for initiating tendon mobilization, the effect of wrist
positioning on tendon gliding force and excursion, and the
Clinical tips application of early active tension on the repaired tendon.34,35

Extensor tendon
Timing
• Uncomplicated mallet injuries are best treated with contin-
uous immobilization in DIP joint extension. There is limited In addition to suture strength, initiation of tendon mobili-
evidence demonstrating superiority of one orthosis over zation must take into consideration factors that increase the
another; however, compliance with orthosis wear affects work of flexion, or the sum of resistance to tendon gliding,36
outcome and the clinician must consider what orthosis may which can put the repair at risk for rupture during the early
be best tolerated. postoperative period. The presence of postoperative edema
• There is growing support in the literature and clinical practice is one known factor that greatly influences resistance to ten-
for treating both chronic and acute zone III boutonnière inju- don glide. In vivo studies examining the effect of edema on
ries with an early mobilization program, such as Evans’ short the force of tendon gliding have found progressive increase
arc motion protocol or Merritt’s RMF orthosis. in resistance to motion during the initial 4 days following
• Treatment for zone V–VII injury has shifted away from con- surgery, with more severe edema corresponding to greater
tinuous MCP joint immobilization towards an ICAM protocol tendon gliding force and work of flexion.37 Zhao et al.38 found
using the RME orthosis, with or without wrist immobilization. day 5 to have the most favorable ratio of repair strength to
force needed to overcome gliding resistance. Additionally, the
• Due to the dorsal extensor expansion contributing to thumb
period of tendon weakening described as “lag time” by Mason
IP extension, thumb EPL ruptures can be missed. Once
and Allen39 corresponds to a loss of strength and tension in the
identified, they often require a tendon transfer with EIP to
tendon during the first 20 days following repair. This occurs
EPL being the most common, followed by a short course of
when the tendon is immobilized; however, Gelberman et al.40
immobilization and progressive active mobilization.
have shown that this does not occur in tendons mobilized

immediately following surgery and that tendons that undergo

early motion have significantly stronger tensile strength at 3
Motion
weeks compared to immobilized tendons. This and support- Various postoperative mobilization regimens have been
ing literature indicate the optimal time to initiate motion is described in the literature and include immobilization, early
4–5 days postoperatively, when wound inflammation and passive mobilization, and EAM protocols. While immobiliza-
edema begin to subside, but before adhesions have formed tion may still be utilized in special circumstances, the appli-
and the repaired tendon loses gliding function.38,41,42 cation of early motion to the healing tendon has been shown
to promote intrinsic healing, result in higher tensile strength,
improve tendon excursion and decrease adhesion formation
Positioning compared with complete immobilization.49 Early passive
The initial postoperative course includes the fabrication of a mobilization protocols50,51 continue to be used in the US and
dorsal blocking orthosis traditionally positioning the wrist worldwide, though there is a general trend towards early
and MCP joints in flexion to limit tension on the repair site. active mobilization protocols.52–54.
However, there has been a shift in literature and clinical prac- The use of early active “place-hold” mobilization was
tice in favor of positioning the wrist more comfortably in neu- developed in consideration for the benefits of synergistic
tral or extension, with the MCP joints in less flexion in order to wrist motion and is an exercise in which the patient is taught
improve tendon excursion, decrease passive extrinsic exten- to passively flex the digits and actively contract to maintain
sor tendon tension, and decrease the work of flexion.35,43–46 flexion while their wrist is passively extended. The wrist
Alternatively, the Manchester Short Splint allows full wrist is then moved into full flexion while the digits are relaxed
flexion and blocks the wrist at 45° extension, leveraging the into extension (Fig. 43.7).55 Synergistic wrist motion has been
tenodesis effect to promote differential glide and minimize the shown to create the greatest amount of differential tendon
work of flexion. Permitting full wrist flexion facilitates IP joint excursion, encourage proximal gliding of the flexor tendons
extension thereby minimizing PIP joint extension deficits. A to mobilize the repair site away from the injury site, and
retrospective study comparing the Manchester splint to the decrease the passive resistance from extrinsic extensors.38,56
traditional forearm-based dorsal blocking orthosis demon- A comparative study of active place-hold mobilization with
strated significantly less PIP joint flexion contractures, greater passive mobilization following four-strand repair of zone
arc of DIP joint flexion, and greater proportion of patients with II flexor tendons found statistically significant increases in
excellent/good Strickland criteria outcomes in the Manchester total active motion and greater satisfaction scores with place-
group.47 As this approach becomes more integrated into clin- hold mobilization protocols without an increase in tendon
ical practice, additional outcome studies will help clarify the rupture rates.57
risks and benefits of minimizing wrist immobilization. Over the past 15 years there has been an increasing trend
Recently, the use of the RMF orthosis has been described by towards the use of early active mobilization incorporating true
Henry and Howell as an early active motion (EAM) approach active flexion exercises of the digit within the first postopera-
for the postoperative management of zone I and II flexor digi- tive week. A general consensus among proponents of short arc
torum profundus (FDP) repairs. By positioning the MCP joint active flexion is the allowance of up to a ½ fist of active flex-
of the affected digit into moderate flexion relative to adjacent ion in a comfortable resistance-free range within the dorsal
MCP joints, the RMF induces a quadrigia effect on the repaired blocking orthosis during the initial 3 weeks postoperatively
FDP tendon, limiting its excursion and force of flexion while while avoiding the final 1 3 range where the work of flexion
permitting finger ROM and functional hand use within the is the greatest58 (Fig. 43.8). Advocates of this EAM approach
orthosis. A series of case studies by the same authors have suggest that surgical advances including multistrand repairs,
shown good initial outcomes; however, more rigorous stud- the judicious venting of critical pulleys, wide-awake surgery
ies in the future will be useful in determining the safety and and intraoperative testing techniques are able to create repairs
efficacy of the RMF orthosis in flexor tendon rehabilitation.48 with minimal gliding restrictions strong enough to withstand

Figure 43.7 (A,B) Synergistic wrist motion is a low

force exercise that facilitates high tendon excursion and is
safe and effective during the early phase of flexor tendon A B
rehabilitation. (Courtesy of Minnie Mau, OTR/L, CHT.)

Table 43.1 Progressive forces associated with flexor tendon

rehabilitation exercise*

Exercise Estimated force (N, Newtons)

Protected passive flexion/ 0.1–1 N Schuind61
extension 2 N Sapineza62
Synergistic wrist extension 1 N Sapienza62
with finger flexion
Short arc active flexion 3 N Evans34
Place-hold in full flexion 5 N Sapienza62
(wrist neutral)
Full arc flexion and 4–9 N Greenwald et al.63
extension/active composite 20–40 N Evans34
fist 20–29 N Schuind61
Active straight fist 8–11 N Greenwald et al.63
Active hook fist 10–13 N Greenwald et al.63
6 N Sapienza112
Active isolated proximal 9N Schuind61
interphalangeal joint flexion
Active isolated distal 19 N Schuind61
interphalangeal joint flexion 9 N Sapienza62
*
A thorough understanding of the forces associated with flexor tendon
rehabilitation exercise is necessary to guide progression of treatment safely and
effectively. Note that a typical 4-strand repair can withstand 40 N of force; however,
edema, joint stiffness and restriction at the pulley will increase the work of flexion.
Figure 43.8 A marked tongue depressor may provide a useful visual and kinesthetic
guide for initiating and progressing active finger flexion in patients who may be either
fearful or overzealous with understanding the limits of short arc motion following
flexor tendon repair. Additionally, it may be a useful way to guide motion at the
isolated joint motion and resistive exercise (Table 43.1, Fig.
distal interphalangeal joint to facilitate flexor digitorum profundus glide. (Courtesy of
Minnie Mau, OTR/L, CHT.) 43.9). Typically, the protective orthosis is discharged at 6
weeks with full return to activity between 12 and 16 weeks
(Table 43.2)
Clinical tips There is some evidence in the literature showing that
EAM protocols result in improved ROM, decreased PIP joint
Flexor tendon extension deficits and improved functional outcomes; how-
• Early active motion is ideally initiated between postoperative ever, side by side comparison of flexor tendon rehabilitation
days 4 and 5 when edema begins to subside, but before the protocols continues to be limited due to variations in proto-
repaired tendon undergoes a period weakening or adhesion cols, injury characteristics, surgical techniques and materi-
formation limits tendon glide. als, as well as differences in reporting patient noncompliance
• Precede AROM exercises with passive flexion exercises to ruptures.60,64–67 Additionally, the use of EAM terminology is
reduce the gliding resistance from edema and joint stiffness, inclusive of place-hold mobilization as well as true active
thereby decreasing the work of flexion when performing flexion exercises that vary in the range of flexion allowed,
active flexion. making direct comparison of protocols challenging. The
selection of a rehabilitative approach following flexor ten-
• Emphasize progression of slow, controlled, mid-range active
don injury continues to require thoughtful consideration and
finger flexion in a comfortable range avoiding full composite
appreciation for surgical factors, patient characteristics, and
flexion in the early postoperative period.
the individual needs and capabilities of the patient and their
• Synergistic wrist motion has been shown to be a low-force
care team.
high-excursion exercise following flexor tendon repair and is
safe to perform during the initial 3 weeks postoperatively.
• Prevent extension deficits by emphasizing protected PIP
Tenolysis
extension early through orthotic positioning and exercise. When a patient fails to progress in the rehabilitation of flexor
• Emphasize DIP joint motion to achieve complete excursion or extensor tendon injuries, a tenolysis procedure may be indi-
of the FDP and differential excursion between FDP and FDS. cated to release adhesions restricting tendon glide. Prior to a
tenolysis procedure, full passive motion of the digit and tissue
the forces of early active mobilization regimens.43,44,59,60 By 4 healing equilibrium should be achieved. Patients should be
weeks postoperatively, regardless of the initial EAM regimen thoroughly informed and prepared for the commitment to a
chosen, sequential progression of exercises includes tendon rigorous therapy program to maximize the outcomes of this
gliding in straight, hook, and full fist positions followed by procedure.

A B C

D E

Figure 43.9 Sequential progression of flexor tendon rehabilitation exercise. (A) Straight fist; (B) hook fist; (C) composite fist; (D) proximal interphalangeal joint blocking; (E)
distal interphalangeal joint blocking. (Courtesy of Minnie Mau, OTR/L, CHT.)

Following tenolysis, the surgeon and therapist need to made to avoid overstretching and attenuation of the tenolysed
have a good understanding of the integrity of the tenolysed extensor tendon by overly aggressive passive flexion, which
tendons. Communication of operative findings is critical. may contribute to an existing extensor lag that will be espe-
Tendons of good integrity may be able to undergo a more cially challenging to rehabilitate. The use of the RME orthosis
vigorous postoperative course of rehabilitation, whereas ten- may improve flexor and extensor tendon gliding while allow-
dons of poorer quality may be at risk for rupture and require ing the patient to continue to progress functional use of their
a protected or graded rehabilitation program. Initiation of hand.
motion following a tenolysis should begin early, and in the While rehabilitation following a tenolysis procedure tends
authors’ experience some surgeons may advocate for ROM to be approached more aggressively than the initial tendon
to begin within 24 hours of surgery. Post-surgical rehabilita- repair, care should be taken to avoid overly vigorous ROM
tion includes wound care, edema management, PROM, active which may cause increased bleeding, pain, inflammation and
tendon gliding, place-hold, isolated joint blocking, as well as edema, resulting in increased adhesion formation and poor
reverse blocking exercises to encourage active PIP joint exten- outcomes following a secondary procedure. As early active
sion to prevent a flexion contracture. Consideration should be motion protocols become the mainstay of flexor and extensor

strength, total active motion of digits, deformity correction

Table 43.2 Current flexor tendon rehabilitation protocol, Stanford
and tendon transfer integration were significantly superior
Hospital Hand Therapy Department
compared with the immobilization group without adverse
Week Orthoses Exercise outcomes of tendon ruptures or insertion pull-out. However,
both groups performed equivocally in the long term, indicat-
Week Dorsal blocking orthosis Passive range of motion ing short-term benefit for EAM, but inconclusive results for
0–3.5 (DBS) with wrist Place-hold flexion in half fist long-term benefits.
positioned in neutral to Synergistic wrist motion During the early postoperative phase, rehabilitation is
slight extension, MCP Active half fist focused on edema control, scar management, and main-
joints flexed 30–50°, IP taining ROM of the uninvolved adjacent joints. When the
joints fully extended, transferred tendon is strong enough to tolerate motion,
worn full time rehabilitation starts with a graded progression of protected
Week Continue with DBS Progress active digital flexion motion. Emphasis is placed on teaching the patient to identify
3.5–6 Add volar gutter for PIP and extension and activate the tendon transfer to perform its new function.
extension if needed at Initiate tendon gliding During this phase of rehabilitation, biofeedback and neuro-
night exercises muscular electrical stimulation (NMES) may be used to help
May start joint blocking of facilitate motor learning and control. Biofeedback provides
PIP with lateral stabilization visual or auditory feedback, while NMES provides tactile
Week Discharge dorsal Continue joint blocking, and proprioceptive feedback when the targeted muscle con-
6–8 blocking orthosis tendon gliding, and active tracts. Motion is initiated in a gravity-eliminated plane, pro-
flexion gressed to place-hold exercises and finally full motion against
Progression back to full gravity. To retrain the tendon transfer, the patient is taught to
activity incorporate simultaneous activation of the donor and recip-
Strengthening for return to ient muscles until isolated activation of the recipient muscle
work or sport as needed can be achieved. As ROM and control of the tendon transfer
improves, the protective orthosis is gradually weaned and
MCP, Metacarpophalangeal; PIP, proximal interphalangeal.
discontinued about 6–8 weeks postoperatively. No matter the
rehabilitation protocol or timeline for starting motion, care
should be taken to limit excessive tension on the repair and
tendon rehabilitation, AROM is ideally recovered during prevent overstretching of the tendon transfer which can lead
early motion rather than relying on dramatic improvement to loss of strength and efficiency.
following tenolysis.

Tendon transfer Rehabilitation following nerve injury

Rehabilitation following tendon transfer surgery is directed Nerve decompression
at protecting the healing tendon, minimizing adhesions, and
ensuring the newly restored function is integrated into the
overall motor pattern.68 Rehabilitation prior to tendon trans- Carpal tunnel release
fer surgery can also be vital to the success of a tendon trans- Following a carpal tunnel release, patients are typically
fer. Considerations in preoperative therapy include educating instructed on unrestricted ROM of their wrist and digits to
the patient regarding post-surgical expectations, achieving tolerance. Sutures are removed by 10–14 days and patients
adequate suppleness of the joints to maximize passive are taught scar massage and desensitization exercises if
motion, as well as strengthening the donor tendon strength needed. Occasionally, patients may need additional inter-
to at least 4+/5, as preoperative ROM will not be exceeded ventions including pain and edema management, nerve
by active motion and loss of strength by one grade will occur gliding exercises, tendon gliding exercises, sensory retrain-
postoperatively.69 ing, and strengthening. Most patients recover well without
During the initial postoperative period, a bulky dressing the need for formal therapy and are able to return to work
or custom orthosis is applied with careful positioning of the by 4 weeks.72
limb to take tension off the transfer. Tendon transfers are typ-
ically immobilized 3–5 weeks prior to allow for healing at
the new tendon insertion site.70 Over the past decade there
Cubital tunnel release
has been a trend towards early mobilization of tendon trans- Postoperative instruction following cubital tunnel surgery
fers consistent with the principles of rehabilitation follow- varies widely with surgical technique and surgeon pref-
ing tendon repair.71 Potential benefits of early mobilization erence. Immobilization may be indicated to protect and
following tendon transfer surgery may include improving rest the healing structures as well as to prevent hematoma
tendon glide and excursion, reducing adhesion formation, formation during the initial postoperative period. Gentle
decreasing swelling, and limiting muscle atrophy and joint motion is initiated early if possible, within a comfortable
stiffness. A systematic review71 found reduced total cost range that avoids placing tension on the nerve. Patients
and rehabilitation time when an EAM protocol was started are not typically restricted with motion following an in situ
within a week of tendon transfer surgery. In the initial ulnar nerve decompression and are able to progress use of their
phase of rehabilitation, measures of ROM, grip and pinch extremity to comfort immediately. Scar tissue mobilization,

desensitization and ulnar nerve gliding exercises may be prevent loss of muscle mass and restore permanently dener-
utilized if the patient presents with pain or hypersensitivity vated muscles to near-normal size in animal and human
that limits function. Following an ulnar nerve transposition, in models if applied at an early enough stage.79 However, fur-
which the ulnar nerve is transferred anterior to the elbow, ther studies are still needed to determine the feasibility and
patients may be immobilized in their postoperative dressing efficacy of application of electrical stimulation in clinical
for up to 2 weeks for comfort and protection prior to initia- settings.
tion of ROM and return to activity. Following a submuscular
ulnar nerve transposition, the ulnar nerve is relocated anterior
to the elbow underneath or within the flexor–pronator mus-
Sensory re-education
cles. Traditionally, the elbow is immobilized in a long arm It is well understood that immediate changes occur in the
orthosis positioning the elbow at 90° of flexion for 3–4 weeks peripheral and central nervous system following peripheral
and elbow extension is progressed gradually to limit tension nerve injury and that early use of sensory re-education tech-
on the repaired muscles.73 In clinical practice, some surgeons niques prior to reinnervation has the potential to improve
allow for early motion with or without elbow immobiliza- long-term sensory recovery.80,81 As reinnervation occurs,
tion to decrease postoperative stiffness and the incidence of axonal misdirection results in reorganization of the somato-
flexion contractures. sensory cortex with an altered map of the areas originally
innervated by the damaged nerve.82–84 Sensory re-education
Nerve repair is directed at modulating the cortical connections and cortical
maps utilizing specific sensory exercises to restore the ability
In the early postoperative period following nerve repair, the of the brain to interpret the altered cortical hand map.
affected limb is immobilized to protect the nerve coaptation. During the early phase of sensory re-education prior to
Typically, nerve repairs are immobilized for up to 3 weeks to reinnervation, alternative sensory input such as vision and
decrease tension on the repair, protect healing structures, and hearing are used to guide sensory feedback.85 The patient may
prevent overstretching denervated muscles. Comparatively, be instructed on exercises that involve imagining or observ-
nerve grafts and transfers are repaired under less tension and ing the shape and texture of an object, a motor action, or their
immobilized for shorter periods (10–14 days). Recent litera- hand being touched to stimulate the somatosensory cortex.
ture indicates that digital nerve repairs may benefit from early Similarly, listening to the sound of a hand being touched or
mobilization without adverse outcomes.74 Communication a hand touching various textures has been shown to activate
with the surgeon to understand the tension under which any the somatosensory cortex and provide beneficial effects for
nerve repair is performed will help guide the course of post- improving recovery of hand dexterity.86,87
operative rehabilitation to maximize outcomes. Mirror visual feedback (MVF) has also been extensively
During the initial period of immobilization, early reha- studied as a strategy for maintaining cortical representa-
bilitation strategies are directed at managing pain and tion and has been demonstrated to activate motor and sen-
edema, protecting areas of diminished or absent sensation, sory areas in the brain. The concept of MVF uses a mirror
maintaining ROM of uninvolved joints, and avoiding com- image of the non-injured hand to project the illusion of the
pensatory substitution patterns.75 Once commenced, rehabil- appearance and movement of the injured hand. This has been
itation prioritizes regaining ROM. Motion may begin with shown to stimulate activity within the primary visual and
place-hold exercises and progress to AROM with gravity somatosensory areas and increase activity in the motor
eliminated until full ROM against gravity can be achieved. cortex, resulting in improvement in motor function of the
Biofeedback and NMES may be useful to help aid in the rec- affected hand.88
ognition and activation of the desired muscle contraction. The late phase of sensory re-education begins once measur-
Additionally, these modalities may be used to inhibit com- able sensibility is present in the hand. This phase is directed
pensatory or antagonistic muscles.76 Once active motion can at re-establishing and strengthening the neural connections in
be achieved against gravity, strengthening is progressed the somatosensory and motor cortex. Exercises are selected
with resisted exercises and rehabilitation strategies are to guide the recovery of tactile gnosis and object recognition,
directed at helping the patient regain functional use of their identification of shapes, textures, objects with and without
affected extremity. vision, grading size, shape, weight, and temperature of objects
The role of electrical stimulation to facilitate nerve regen- and using bilateral tactile stimulation.85,89
eration following peripheral nerve injury is well described
in the literature. Findings from animal studies have demon-
strated accelerated peripheral nerve regeneration following
Desensitization
application of brief, low frequency electrical stimulation after If hyperesthesia and allodynia are present following a nerve
nerve repair.77 In human subjects, Gordon et al.78 have found injury, desensitization techniques should precede sensory
increase in number of motor units, improved terminal motor re-education exercises to maximize patient comfort and par-
latency and sensory nerve conduction values in patients with ticipation in rehabilitation. Desensitization involves progres-
severe carpal tunnel syndrome and thenar muscle denerva- sive stimulation to the painful areas of the hand to reduce
tion who underwent 1 hour of electrical stimulation at 20 Hz hypersensitivity beginning at the patient’s level of tolerance
following surgical nerve decompression. with tapping, rubbing, or touching the skin with a texture just
The effectiveness of electrical stimulation for treatment of above a level of discomfort. Treatment is progressed by apply-
denervated muscle following nerve injury continues to be ing increasingly irritating textures and materials, with the
investigated. Various studies have demonstrated that elec- goal of increasing the patient’s threshold of nerve stimulation
trical stimulation of sufficient intensity has the capacity to to minimize discomfort (Fig. 43.10).89

Progressive textures
Cotton fabric Tapping
Flannel
Denim
Light
Burlap Brushing
touch
Velcro

Desensitization Program

Moving Figure 43.10 A desensitization protocol begins

Particle immersion
touch with the application of a slightly intolerable
Cotton balls sensation over the hypersensitive area until the
Rice Vibration area is numb or no longer sensitive and progresses
Rubbing Beans with increasingly irritating textures and materials
Sand with the goal of decreasing or eliminating the areas
Macaroni of hypersensitivity and discomfort. (Courtesy of
Minnie Mau, OTR/L, CHT.)

Nerve transfer
focused practice and repetition during early stages of motor
The use of nerve transfers has become well integrated into learning. Repetition and massed practice are fundamental
clinical practice, providing an opportunity for restoring concepts to master motor skills and may help reinforce newly
meaningful function following nerve injury when recovery by formed cortical connections.82,83
nerve repair cannot be expected. Prior to and following nerve
transfer surgery, it is essential that patients are thoroughly
educated on the new and altered anatomy, the expected time-
Anterior interosseous nerve to ulnar motor nerve
lines for nerve reinnervation and realistic expectations for Following a high ulnar nerve injury, the terminal branch of
recovery to maximize their motivation and compliance. In the the anterior interosseous nerve (AIN) can be harvested as a
initial postoperative phase, patients are taught ROM exercises donor transfer to the ulnar motor nerve distally via an end-to-
to maintain joint mobility and prepare the affected limb for end or end-to-side anastomosis in order to improve intrinsic
return of function. Immobilization may be used in between hand function with good results.92 Incorporating a donor acti-
exercise sessions to preserve muscle length in order to maxi- vation-focused rehabilitation approach, patients are taught
mize functional recovery once reinnervation occurs.90 to activate the donor pronator quadratus muscle with active
forearm pronation exercises. An anti-claw orthosis (Fig. 43.11)
is utilized between exercise sessions to avoid overstretching
Motor re-education of the intrinsic muscles and prevent PIP joint contractures.
Motor re-education is of particular importance following a Once a muscle twitch is observed in the recipient intrin-
nerve transfer procedure, as the neural pathways have been sic muscles, usually within 6–8 months, patients are taught
altered, and the donor nerve is expected to take over a new simultaneous contraction of the donor and recipient muscles
function. Patients must learn to activate the prior function of via finger abduction/adduction and pronation (Fig. 43.12).
the nerve (the donor muscle) to be able to activate the recipient
muscle once nerve regeneration occurs. The patient is taught
to perform frequent high-repetition low-resistance exercises Clinical tips
contracting the donor muscle in order to strengthen the new
neural pathway while awaiting reinnervation to the recipient Nerve repair
muscle. Once recipient muscle reinnervation is evident, the • Sensory re-education is directed at modulating cortical
patient is taught co-contraction of the donor and recipient maps using alternative sensory input such as vision and
muscles simultaneously to further strengthen the cortical con- hearing to guide sensory feedback and should be incor-
nections in addition to increasing muscle bulk in the recipient porated early prior to nerve reinnervation.
muscle. One important consideration as the recipient muscle • If hyperesthesia is present, desensitization exercises using
gains strength is to limit high-intensity exercise as this may progressively tolerable stimulation should precede sensory
have negative effects on axonal regeneration.91 re-education in order to maximize patient’s comfort and
Functional magnetic resonance imaging studies have participation in their rehabilitation.
demonstrated expansion of motor cortical representation • Following nerve transfer surgery, high-repetition low-resis-
when learning and practicing a new motor skill.83 Proposed tance exercises contracting the donor muscle will strengthen
strategies to maximize motor relearning following nerve the altered neural pathways while limiting fatigue.
transfers include: preoperative training and practice of the
• Repetition and massed practice may help reinforce newly
movements to activate the nerve transfer, early activation of
formed cortical connections following motor nerve injury.
motor movement with resistance or gravity eliminated, and

As the recipient muscles gain strength, resistive exercises and

dexterity can be progressed with emphasis on re-learning the
original movement patterns until the patient is able to incor-
porate use of their hand into their daily function.

Rehabilitation following fractures

Fracture management has evolved from the concept of stability
as one point in time towards the idea of relative stability that pro-
gresses throughout the phases of fracture healing. The goal of
fracture healing is to achieve bone healing and recovery of motion
simultaneously rather than consecutively.93 Soft-tissue stresses
should not jeopardize fracture stability and methods to achieve
stability should not cause unnecessary harm to soft tissues.94
When a fracture is considered stable, the deforming forces do not
affect its alignment during early mobilization of adjacent joints.
Stable, non-displaced fractures treated with closed reduc-
tion avoid the potential complications associated with sur-
gery; however, a prolonged period of immobilization is
required to allow for fracture callus formation. Fractures that
are treated operatively with internal fixation have added sta-
bility and may often be mobilized sooner.94 Regardless of the
type of fracture reduction, both methods of healing adversely
affect the soft-tissue layers and the function of the extremity
due to immobilization and scar adhesion formation.
Figure 43.11 The anti-claw orthosis, also known as a lumbrical blocking orthosis,
positions the metacarpal phalangeal joints in flexion to prevent hyperextension and Although extra-articular and intra-articular fractures are
facilitates interphalangeal joint extension creating a more functional grasp. (Courtesy distinctly different in their needs for reduction and stabil-
of Minnie Mau, OTR/L, CHT.) ity, both types of fractures may benefit from an early motion
program that does not overload vulnerable tissue. Variability
exists in both literature and clinical practice regarding orthosis
selection, duration of immobilization as well as progression of
motion and activity. Four phases of therapy have been described
to guide fracture rehabilitation: (1) protective, (2) restorative,
(3) strengthening, and (4) functional.95 These phases of therapy
and interventions overlap and have clinical application during
more than one phase of therapy (Table 43.3).

Protective phase
During the protective phase of healing, the patient is placed
in an orthosis that controls edema, protects the fracture from
external forces and positions the joints opposite the pattern
of deformity. For simple, closed, extra-articular long bone
fractures, such as metacarpal shaft fractures, the belief that
immobilization of a fracture must always include the joints
above and below has been challenged with the introduction
of fracture bracing. By allowing some mobility of the soft tis-
sue at the fracture site osteogenesis can be enhanced.96 Unlike
intra-articular fractures, not all extra-articular fractures may
require a period of immobilization, especially if they are
treated with rigid fixation. Orthosis selection during this pro-
tective phase must take into consideration the type of pro-
tection required, fracture stability and type of bone healing
(primary vs. secondary), patient lifestyle, compliance as well
as surgeon preference (Table 43.4).

Restorative phase
Figure 43.12 Following an anterior interosseous nerve to ulnar motor nerve transfer,
exercises contracting the donor nerve muscle (pronator quadratus) and recipient As the fracture begins to show radiographic evidence of heal-
muscles (interossei) are performed simultaneously and progressively strengthened ing, or fixation is such that it can undergo early controlled
with resistance. (Courtesy of Minnie Mau, OTR/L, CHT.) motion, the restorative phase of rehabilitation begins. Most

Table 43.3 Michlovitz95 divides fracture management into four

phases to guide rehabilitation

Phases of
therapy Primary goal(s) Interventions
Phase I Protecting injured Orthosis selection and
Protective structures by limiting fabrication
or preventing joint Modalities for pain
motion and load management
Managing pain, Massage, elevation, and
edema and compression for edema
inflammation management
Phase II Restore motion AROM including tendon
Restorative glide, PROM, joint
mobilization, manual
edema mobilization
Phase III Increase motion, Progress to full arc of
Strengthening strength, and motion, strengthening,
endurance gripping, load-bearing
Phase IV Return to work and Patient-specific
Functional pre-morbid activity vocational and
avocational activity
AROM, Active range of motion; PROM, passive range of motion.
Figure 43.13 In the presence of chronic or subacute edema, the use of a low-
stretch elastic bandage such as Elastomull or Kerlix may be useful for providing
compression to each digit while keeping the palm and tips free for functional hand
Table 43.4 Orthosis considerations for hand fractures use. (Courtesy of Wendy Moore, OTR/L, CHT.)
Fracture Location Orthosis considerations
Metacarpal Shaft/MCP Hand or forearm-based radial/ulnar is critical for patient comfort and restoration of early mobil-
fractures joint gutter, MCP joint flexed 50–70°, IP ity. Edema management techniques include elevation, com-
joints free pression wrapping, massage techniques, and AROM.98,99 For
Hand-based “cuff” orthosis with subacute or chronic hand edema, wrapping of the hand with
MCP joint free a low-stretch bandage may be beneficial to decrease the col-
loid pressure in the interstitial space while allowing for finger
Proximal Shaft Soft-tissue injury
motion to encourage muscle pumping (Fig. 43.13).100
phalanx Intra-articular/ Hand-based radial/ulnar gutter with
AROM exercises are initiated early to enhance lymphatic
fractures PIP joint MCP joint flexed 50–70°, IP joints
drainage, generate tendon gliding, and promote strength
injuries free
and endurance.98 Patients are advised to let pain guide their
Dorsal finger extension blocking
motion, allowing for gradual progressive motion to maintain
PIP joint in 15–40° of flexion (MCP
fracture reduction.101 During this time, parameters for motion
joint in flexion or free)
can be established to limit arc, type of motion, direction, fre-
Buddy straps
quency, conditions (with/without protective orthosis), and
Middle Shaft Hand-based radial/ulnar gutter, the number of moving joints.102 Limiting the length of immo-
phalanx Intra-articular/ MCP joint flexed 50–70°, IP joints in bilization and allowing for motion even with a limited arc will
fractures PIP joint extension lead to a better final result.103,104
Dorsal finger extension blocking
PIP joint in 15–40° of flexion (MCP
joint in flexion or free)
Strengthening and functional phase
Buddy straps By 3–4 weeks post closed reduction, or earlier with internal
Distal Shaft/tuft Digit/cap orthosis fixation, most fractures have enough structural strength to
phalanx Intra-articular/ DIP joint in extension withstand full arc active motion and light functional activ-
fractures DIP joint ity.102 As fracture healing allows, PROM and resisted motion
DIP, Distal interphalangeal; MCP, metacarpophalangeal; PIP, proximal interphalangeal.
are incorporated into the therapy regimen. By 6–8 weeks,
patients are typically able to return to work and low-demand
recreational activity.
fractures have limited stability within the first week post
injury and selection of an appropriate protective orthosis Metacarpal fractures
may allow tolerance of some controlled motion.97 Therapeutic
modalities such as heat, ice, ultrasound, and electrical stimu- The biomechanical relationship of the intrinsic and extrinsic
lation may be appropriate for managing pain. Edema control muscles in the hand relies on the skeletal stability of the

provide adequate stabilization while allowing early motion.

Alternatively, the use of a hand-based orthosis immobilizing
the MCP joints in flexion and leaving the IP joints free may
be sufficient to reduce the fracture and provide compressive
forces to stabilize the fracture fragments while preventing IP
joint stiffness (Fig. 43.14).93,106,107 The orthosis can be discharged
at 3–4 weeks post injury with PROM and strengthening
initiated by 6 weeks.

Distal phalanx fractures

Distal phalanx fractures are one of the most common fractures
in the hand in both adults and children, often resulting from
getting the finger caught between two objects. These injuries
tend to be easier to rehabilitate than other fractures of the
hand, as they are commonly extra-articular and the anatomic
relationship of the associated ligamentous and musculoten-
dinous structures is less complex. Most often, disability from
these injuries is due to pain and sensitivity along the distal
phalanx.108 Tuft fractures are often referred to therapy early to
provide wound care at the nail bed in addition to orthotic inter-
vention. The patient may be placed in a cap orthosis protect-
ing the fracture site while allowing ROM of the MCP and PIP
joints. DIP joint motion may begin by 2 weeks after injury with
unrestricted motion typically started by 4 weeks. Bony mal-
let injuries require full-time extension immobilization for 6–8
weeks to allow for full healing of the terminal extensor tendon.

Figure 43.14 A hand-based ulnar gutter orthosis positioning the

Rehabilitation following replantation
metacarpophalangeal joints in flexion leaving the interphalangeal joints free may be A successful replantation relies not only on survival of the
sufficient to stabilize a proximal phalanx fracture while minimizing finger stiffness.
(Courtesy of Wendy Moore, OTR/L, CHT.)
amputated extremity and healing of the repaired tissue, but
also on the dynamic return of motion. Since the initial suc-
cessful thumb replantation was described in 1968, digital
metacarpals. When these long bones are fractured, the adjacent replantation has grown in popularity due to increasing suc-
muscles may produce deforming forces that are counterpro- cess rates from advancements of microsurgical techniques.109
ductive to successful fracture management. Metacarpal neck Traditionally, replantation has been recommended for the
fractures, also called boxer’s fractures, are the most common following: amputation of the thumb at all levels, amputation
of all metacarpal fractures. They are considered extra-articu- of multiple digits, amputations in children, and single fin-
lar fractures and usually involve the small and ring fingers. ger amputations distal to the flexor digitorum superficialis
These, along with shaft fractures, may be treated conserva- insertion.110
tively or with surgical intervention depending on length, The success of the replanted digit can be determined after
digit rotation, and alignment. Patients are placed in a radial the first 7–10 days after surgery. If successful, the postopera-
or ulnar gutter orthosis for 3–4 weeks with the MCP joints tive rehabilitative process then begins. Due to the complex-
positioned in flexion and the IP joints free for unrestricted ity of any replantation, communication between the surgeon,
motion. The wrist may be included in the orthosis depending patient, and hand therapist is essential. The therapist must
on surgeon preference and patient’s activity level. Patients are consider the nature of the injury, fracture fixation, quality of
instructed on progressive digit ROM including extensor dig- tendon and nerve repair, soft tissue, and vascular involve-
itorum communis (EDC) gliding exercises and finger abduc- ment. In the initial phase of rehabilitation, the therapist will
tion and adduction exercises to activate the interossei muscles perform wound care, fabricate an orthosis to best position the
and prevent an extension lag.105 PROM and strengthening hand, manage edema, and maintain ROM of the unaffected
may be introduced by 6 weeks post injury. adjacent digits and extremities.
An orthosis may be fabricated within the first 1–2 weeks
Proximal/middle phalanx fractures following replant. If skin grafts are used, the therapist should
be mindful of avoiding shearing forces from the orthosis until
Proximal phalangeal fractures are often difficult to treat the graft has healed. Understanding of the vascular supply is
whether operatively and nonoperatively. To promote bone also critical to avoiding pressure points, primarily with strap-
healing and recovery of motion at the same time, treatment ping, which may compromise the replantation. Hand and
is focused on creating skeletal stability to allow for func- digital replants are typically immobilized in a dorsal blocking
tional movement while preventing stiffness. In non-dis- orthosis, positioning the wrist in neutral, MCP joints in flex-
placed, stable proximal phalanx fractures, buddy straps may ion, and IP joints in full extension. A Muenster component that

Figure 43.15 Eight weeks following a toe-to-thumb

replant, this patient has excellent prehension for fine
motor (A) and gross motor (B) tasks. (Courtesy of Wendy
A B
Moore, OTR/L, CHT.)

limits forearm rotation may be added if the amputation is at fixation crossing the IP joints or MCP joint of the thumb may
the level of the wrist and the distal radioulnar joint (DRUJ) is be necessary, prohibiting early motion and delaying the reha-
involved. More proximal replants will likely require the elbow bilitation program. Once fixation is removed, the patient
to be positioned in about 70° of flexion. For thumb replants, is instructed in PROM and progressed to AROM with an
a spica or radial dorsal blocking orthosis may be indicated, increasing arc of motion.
positioning the thumb in abduction and slight flexion, wrist For amputations at and above the forearm level, the mech-
in neutral position, and the fingers free. Sensory deficits are anism of injury typically affects many structures at varying
common after amputation and it is important for the therapist levels. PROM of the hand is started within the first week after
to instruct the patient to frequently check for skin breakdown, surgery, followed by the shoulder and elbow with consid-
as well as continuously evaluate the health of the wound and eration for concomitant bony and soft tissue repairs. At this
vascularity of the replant. level of amputation, compensatory training in one-handed
In the presence of any severe trauma, proper edema man- ADLs may be helpful to facilitate independence until the
agement is essential for progression of AROM and PROM. replantation is safe for functional re-education.
The primary method for edema management is elevation and Sensory re-education also plays an integral role in the reha-
active ROM of the unaffected joints. Other conventional ther- bilitation program after amputation. In one study, replanted
apies, such as compression and cryotherapy, are usually con- or revascularized digits treated with a sensory re-education
traindicated due to the fragile vascular supply and sensory program had significantly greater sensory recovery than dig-
deficits. Alternatives for edema management include the use its treated without sensory re-education.111 Further emphasis
of kinesiology tape, high voltage pulsed current, and Manual on sensory re-education programs may continue to improve
Edema Mobilization (MEM) techniques.99 These may be indi- the functional results of digital replantation.112
cated in the subacute edema phase if prolonged swelling con- As replantation survival rates have significantly improved,
tinues to impact soft-tissue mobility. so have expectations for function. Due to the complex nature
Early controlled motion, when possible, is started within of these injuries it is not surprising that secondary surger-
the first 7–10 days after replantation to prevent joint contrac- ies are often necessary. Complications most likely to occur
ture and tendon adhesions. Initial motion begins with gentle include malunion/non-union, cold intolerance and sensory
PROM of all digits within the confines of the orthosis. When deficits, stiffness, muscle contracture, and tendon adhesions.
advised by the surgeon, active motion may be performed by The role of the hand therapist throughout this process is
flexing the digits to midrange, approximately 45° at each of essential for maintaining communication with the care team
the three finger joints, and allowing for full extension within and providing guidance on the timing for additional proce-
the constraints of the orthosis. By weeks 3–6, full active com- dures (Fig. 43.15).
posite flexion and differential tendon gliding may be intro-
duced. New scar adhesions will continue to form over this
time and tissue resistance may change. As it is likely that Future directions
both flexors and extensors were repaired, ongoing awareness
of both structures is paramount to achieving adequate digit Advancements in surgical techniques, materials, and meth-
ROM. Although more attention is placed on the flexors due ods have informed and guided advancements in rehabili-
to the functional role they hold, neglect of the extensors may tation. The future of hand therapy continues to evolve with
lead to gapping, attenuation or rupture. decreasing need for prolonged postoperative immobilization
The rehabilitation guidelines for a thumb replant are simi- and promoting early motion and return to activity. There has
lar to those for a finger, although it is more likely that K-wire been an overall trend toward patient-guided decision-making

in the selection and implementation of a treatment approach interdisciplinary care, advances in the use of biologics, and
that emphasizes individualized patient needs over specific novel orthosis materials and fabrication techniques are a few
protocols. of the developments that may lead to changes in patient care.
Improvements in technology will undoubtedly continue to More than ever, collaboration and communication between
provide innovative solutions for surgical and nonoperative surgeons, therapists, and the patient are crucial for optimiz-
management of a variety of diagnoses. Improving access to ing care and maximizing outcomes following upper extremity
telemedicine, electronic medical record systems that enhance injury.

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Hand Therapy

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Hand Therapy

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SECTION VII • New Directions

Access video content for this chapter online at Elsevier eBooks+

SYNOPSIS domains of focus include body functions and structures; activ-

Patient evaluation Impairment-based assessments

Figure 43.1 The figure-of-eight measurement technique for assessing edema

• Occupation-based assessments, such as the QuickDASH, 3

Rehabilitation following tendon injury 7 T5

Extensor tendon injury

Figure 43.6 A relative motion extension orthosis may be

immediately following surgery and that tendons that undergo

Figure 43.7 (A,B) Synergistic wrist motion is a low

Table 43.1 Progressive forces associated with flexor tendon

Exercise Estimated force (N, Newtons)

strength, total active motion of digits, deformity correction

Tendon transfer Rehabilitation following nerve injury

Moving Figure 43.10 A desensitization protocol begins

As the recipient muscles gain strength, resistive exercises and

Rehabilitation following fractures

Table 43.3 Michlovitz95 divides fracture management into four

provide adequate stabilization while allowing early motion.

Distal phalanx fractures

Figure 43.14 A hand-based ulnar gutter orthosis positioning the

Figure 43.15 Eight weeks following a toe-to-thumb

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