Therapy Management Of The Unstable Thumb

Transcription

1 Therapy Management Of The Unstable Thumb Poole Hospital Hand Therapy Bridget Ellis: Advanced Physiotherapy Practitioner Kirsty Bancroft: Senior Occupational Therapist June 2013

2 Trauma v arthritic Which joint is affected in trauma? Which joint in arthritis?

3 Soft tissue injuries MCP Joint Radial Collateral Ligament rarely injured Ulnar Collateral Ligament Grade 1 Sprain / small incomplete tear Grade 2 Partial tear, asymmetrical laxity but firm end point Grade 3 Complete rupture, +/- Stener lesion History Radial stress Pain on pinch loading with feeling of giving way Physical examination Palpation Stress test Further investigations.

4 UCL injury Hand therapy management? Conformity as to approach amongst textbooks and literature No research evidence to support the claims Modified Delphi approach to collate current expert hand therapy practice 2013; Ref: Patel et al, Strategies in trauma & limb reconstruct (1) 1-10 Royal Bournemouth Hospital Winchester Hospital Frenchay Hospital Bristol Southampton General Hospital Chelsea and Westminster Hospital Wellington Hospital BUPA Hospitals Poole Hospital

5 Hand therapy management Grade 1 Traditional management Poole B mth Br l W ch r Soton London Protect/ Immobilise with tape to protect collateral No orthotic/ Ice Gentle non stressed ROM. May use a short hand based spica - 2-3/52 Rare to require orthotic taping except elite sports for play Avoid abd tion/add n exs

6 Hand therapy management Grade 2 - Partial tear Traditional management B mth Poole Br l W ch r Soton London Short arm spica 2-3/52. - hand based Cast / orthotics (hand based) 3-6/52 with exs. Cast / orthotics (hand based) 3-6/52 with exs. - may immob up to 6/52 but remove for exs - hand based 23/52 mobilise dep. on stability 46/52 Protected mobilising post 2-3/52 Dynamic stability, may require protective splint for 6/52-3/12 Light ADL 36/52 Contact sports 612/52 (unprotected) Light ADL 46/52 Avoid abd tion/add n exs Contact sports 6-12/52 (unprotected) Use of step down tape/neopr ene

7 Therapy support options Thermoplastic thumb support Step down neoprene support & taping

8 Exercise options Dynamic stability important Adductor pollicis ulnar stabiliser but caution with overload of pinch in early stages Thenar group

9 Grade 3 Complete rupture +/- Stener lesion, post surgery Traditional management B mth Poole Immobilise POP x 3/52 - hand based Cast / orthotics (hand based) Graded exercise x 4/52 immobilise at other times Light activity x 6/52 with protection Light progressing to full use post 12/52 Sport dependant on clinical findings/repair 34/12 Br l W ch r Cast / orthotics Comme (hand based) nce exs. 23-6/52 with 3/52 3-6/52 with exs. post op exs. Light ADL 4-6/52 Contact sports 612/52 Light ADL 46/52 Contact sports 612/52 unprotected Soton London Commen ce exs. 2-3/52 post op No Stener splint 23/52 then if stable flex/ext only Graded use with support as per Grade 2 No sport & strong pinch x 810/52 If Stener delay 46/52

10 Accelerated rehab. of skier s thumb injury in professional athletes Delaney, Hayton & Tisouri, BAHT/BSSH 2010 Surgical repair 2/7 later hand based removable splint Thumb MCP exercises at 10/7 accelerated rehab including strengthening Early return to sport 14 patients recruited post repair, mean f/u 42/12, longest 5 years No clinical evidence of instability at 1/12 post-op, FROM and power All patients returned to competitive sport at level prior to injury Mean time 3.6 weeks post op. return to sport with protective taping for sport for play for up to 12/52

11 Outcomes & conclusion Outcomes Grade 1 and 2 In adults - early diagnosis of traumatic injury leads to effective & appropriate function Grade 2 - may have persistent symptoms for months but minimal functional impairment need reassurance ++ Early management will significantly improve long-term outcome Outcomes post-op May have persistent symptoms for months post-op but minimal functional impairment May be left with some deficit in ROM if significant injury managed operatively Often significant internal scar with permanent changes in profile of joint

12 Arthritic TEAR TEST... Observe the posture of the thumb to establish the pattern of instability What happens at the IPJ, MCP and CMC during loading? CMCJ inherently unstable, especially in women & ligamentous support weakens with age

13 OA Thumb: Early Stage Of Disease Consider all 3 joints as a source of instability Maintain stability Slow progression of degeneration Control the soft tissue component Pain control Avoid adduction/deforming posture

14 Can I reduce the deformity to an anatomical fit? YES NO Splinting may be useful in influencing pathology Splinting is not going to influence the pathology but may still give pain relief

15 MCP joint instability MCPJ laxity predisposes patients to OA of the thumb (Degreef, De Smet 2006) MCPJ hyperextension with mild CMCJ symptoms & minimal changes on x-ray Splint the MCPJ only to correct hyperextension during function Short term splinting applied to retrain muscle groups in a more stable position

16 CMCJ instability Pain in CMCJ with no MCP hyperextension or IPJ hyperextension Splint the CMCJ (pseudo-hydraulic environment)

17 Strengthening Evidence weak? Effective in established OA Focus exercise on EPB APB Isometric concentric OP Mid range exercise Try and reduce flexion of the CMC

18 Advanced disease Fixed deformity Persistent pain on loading Don t try and correct fixed deformity Splinting for comfort/ reduce loading forces through CMCJ

19 Joint protection Proven to reduce stress through the joints Most demanding pinch function is a lateral pinch e.g. Key grip Pinch load applied at the tip is multiplied x5 at IPJ, x8 at MCP & x at CMCJ PRINCIPLES Spreading the load Change the grip pattern used to perform a task

20 Thank you Who created this?