2019 Philadelphia Meeting Conservative Management of Mallet, Swan Neck, and Boutonniere

Transcription

1 2019 Philadelphia Meeting Conservative Management of Mallet, Swan Neck, and Boutonniere Jeanine Beasley, EdD, OTR, CHT, FAOTA Professor, Grand Valley State University Grand Rapids, Michigan

2 Mallet Finger The extensor tendon is cut or torn from the insertion on the distal phalange. Common causes: sudden, direct impact to the end of the finger and hyperextension - basketballs, footballs, and baseballs. Everyday household activities such as making the bed, doing laundry, etc.

3 Diagnosis Type 1- Result of blunt trauma. Tendon damage may or may not be associated with small avulsion fracture. Type 2- Result of complete rupture or laceration of the tendon. Type 3- Result of deep abrasion. Type 4- Fractures involving more than 20% of the articular surface in adults with greater than 50% volar subluxation of distal phalanx.

4 Treatment If left untreated, mallet finger can lead to a swan neck deformity. Patient compliance is essential Orthosis alone - Type 1 injury Orthosis is also used postoperatively to protect the repaired tendon. Surgical treatment is used more often in Type 2 through 4 injuries and in severe cases. Surgery also is indicated when the person delays treatment.

5 Orthotic Preferences Cook, et al. (2017). How do hand therapists conservatively manage acute, closed mallet finger? A survey of members of the British Association of Hand Therapists. Hand Therapy, 22 (1) Custom orthoses was the favored option 6-8 weeks immobilization Weaning with removable orthosis standard practice

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7 Rolyan Quickcast "2" Custom mallet orthoses had fewer skin complications (Witherow & Peiris, 2015)

8 Weaning from the orthosis Lag increases after discontinuation of the orthosis (Pike, et al., 2010) Lag is worse as age increases (Pike et al., 2010) Weaning with removable orthosis standard practice. (Cook, et al., 2017) Orthosis to be worn at night, heavy loading. Weaning up to 12 weeks (mode = 4 weeks) Avoid DIP PROM weeks

9 Tape Support Under the Orthosis During Donning and Removal Elastic tape (Devan, 2018) Steri-strip (Mak, et al., 2016)

10 If Swan Neck is Developing Include the PIP joint in the orthosis - flexion

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12 Boutonniere and Swan Neck The proximal interphalangeal joints are among the most commonly injured joints of the hand (Chinchalker & Bing, 2003) Swan neck and boutonniere deformities are common in Rheumatoid arthritis (P. Feldon, Terrono, Nalebuff, Millender, 2005). Swan neck deformities have also been reported in Ehler Danlos syndrome (Erçöçen, Yenidünya, Yilmaz, Ozbek, 1997) and benign hypermobility syndrome (Lawrence, 2005).

13 The Delicate Balance

14 Swan-neck: RA, Ehler Danlos syndrome, Cerebral Palsy, Benign Hypermobility Syndrome, and Trauma

15 Orthoses and the Swan-neck Deformity Zijlstra, T.R, HeijnsdijkRouwenhorst, L., & Rasker, J. J. (2004). Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis &Rheumatism, 51(6), Spicka C, Macleod C, Adams J, Metcalf C. Effect of silver ring splint on hand dexterity and grip strength in patients with rheumatoid arthritis: an observational pilot study. Hand Therapy. 2009; 14: (2): Tar Schegget M; Knipping A. A study comparing use and effects of custom-made versus prefabricated splints for swan neck deformity in patients with rheumatoid arthritis. British Journal of Hand Therapy. 2000; 5(4):

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17 Oval 8 Splints: One time adjustment! Patients prefer prefabricated splints for swan neck deformity in RA - Oval 8, Silver Ring Splints, etc. (Tar Schegget, et al. 2000)

18 Trauma: Swan Neck and Dorsal PIP Joint Dislocation Pinned in 20 flexion for 2 weeks (4 weeks with CP) Replaced with dorsal blocking orthosis Active flex/ext in the orthosis-distal strap detached Wean from orthosis at 6 weeks Fox & Chang (2018)

19 Tenodesis: Postoperatively (Fox & Chang, 2018) 2 weeks post digit or hand based dorsal blocking orthosis AROM in the DBO distal straps removed 6 weeks post: weaned from orthosis

20 Boutonniere Acute, nonsurgical Open acute, post surgical Chronic, non surgical Chronic, post surgical Initiation of active movement various in the literature based on condition

21 Boutonniére Deformity Diagnostic Tests Boyes Test (negative) Active flexion of DIP joint is limited when PIP joint is passively positioned in full extension. Modified Elson Test (positive) PIP in 90-degrees flexion. This normally keeps the central band taut and the lateral bands loose. Ask the patient to extend the PIP, while the provider s finger applies counterforce at the middle phalanx. NORMAL Elson s test: Results in active extension of the PIP joint and a floppy DIP. ABNORMAL Elson s test: Results in no active extension of the PIP joint and a slightly extended, taut DIP.

22 Boutonniere Deformity Chronic: attempt serial casting Fractures some start gentle motion 3 weeks after fracture reduction Depending on the soft tissues delay gentle motion 6 weeks Active DIP motion only Lutz, et al. (2015)

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24 Chronic boutonniere: Serial cast until full extension Progress to orthosis for 6-8 weeks DIP AROM important Lutz et al. (2015)

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27 SAM: Short Arc Motion Week 1: flexion to 30 Week 2: flexion to 45 If good extensors no SAM needed during AROM DIP blocking AROM 5-10 reps 5x daily Evans, R. B. (1995) Photos from Ascension web site

28 Relative motion flexion orthosis for long finger boutonniere deformity Lalonde, D. (2015). Managing Boutonniere and swan-neck deformities. BMC Proceedings, 9 (Suppl 3) Merritt, W. H. (2014). Relative Motion Splint: Active Motion After Extensor Tendon Injury and Repair. The Journal of Hand Surgery, 39(6),

29 When do you begin the relative movement orthosis (Lalonde, 2013)? Serial cast until full PIP extension and DIP full active flexion Then begin 8 weeks of full PIP extension orthosis After 8 weeks begin relative motion flexion for an additional 4-8 weeks with night PIP extension orthosis.

30 How much more MP flexion than the other digits? Originally Some studies report Hirth, M. J., Howell, J. W., O'Brien, L. (2016) Relative motion orthoses in the management of various hand conditions: A scoping review. Journal of Hand Therapy, 29(4): doi: /j.jht Epub 2016 Oct 25.

31 Lateral Alignment Issues Conservative Surgical

32 References Cole T, Robinson L, Romero L, O Brien L. (2017). Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: a systematic review. Journal of Hand Therapy. Available online 29 December main.pdf?_tid=3b8da7f0-bff0-435f-a9d0- b3bea75dad75&acdnat= _fd f3d6b3ce86f6060dff803 Chinchalkar, S. J. & Gan, B. S. (2003). Management of proximal interphalangeal joint fractures and dislocations. Journal of Hand Therapy, 16, 2, Doyle, J. R. (1993). Extensor tendons-acute injuries. In Green D. P. (Ed). Operative Hand Surgery. (3rd ed., pp ). New York: Churchill-Livingstone. Erçöçen A. R., Yenidünya, M.O., Yilmaz, S., Ozbek, M.R. (1997) Dynamic swan neck deformity in a patient with Ehlers-Danlos syndrome. Journal of Hand Surgery Br., 22: Handoll, H. H., Vaghela, M. V. (2014). Interventions for treating mallet finger injuries. Cochrane Database Systematic Reviews, 3:CD Hirth, M. J., Howell, J. W., O'Brien, L. (2016) Relative motion orthoses in the management of various hand conditions: A scoping review. Journal of Hand Therapy, 29(4): doi: /j.jht Epub 2016 Oct 25. Lalonde, D. (2015). Managing Boutonniere and swan-neck deformities. BMC Proceedings, 9 (Suppl 3) Lawrence, A. (2005). Benign hypermobility syndrome. Journal of Indian Rheumatology Association,13: Lin J.S., Samora, J.B. (2018). Surgical and nonsurgical management of mallet finger: a systematic review. Journal of Hand Surg Am.43(2):146e163. Merritt, W. H. (2014). Relative Motion Splint: Active Motion After Extensor Tendon Injury and Repair. The Journal of Hand Surgery, 39(6), O Brien, L. J., & Bailey, M. J. (2011). Single blind, prospective, randomized controlled trial comparing dorsal aluminum and custom thermoplastic splints to Stack splint for acute mallet finger. Archives of Physical Medicine and Rehabilitation, 92(2), Pike, J., Mulpuri, K., Metzler, M., Ng, G., Wells, N., Goetz, T. (2010). Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. The Journal of Hand Surgery, 35(4), Porter, B. J., Brittain, A. (2012) Splinting and hand exercise for three common hand deformities in rheumatoid arthritis: a clinical perspective. Current Opinion in Rheumatology, 24(2): doi: /BOR.0b013e Spicka C, Macleod C, Adams J, Metcalf C. (2009) Effect of silver ring splint on hand dexterity and grip strength in patients with rheumatoid arthritis: an observational pilot study. Hand Therapy, 14: (2): Stark, H. H., Boyles, J. H., & Wilson, J. N. (1962). Journal of Bone and Joint Surgery, 44, Tar Schegget M; Knipping A.(2000) A study comparing use and effects of custom-made versus prefabricated splints for swan neck deformity in patients with rheumatoid arthritis. British Journal of Hand Therapy; 5(4): Willoughby, J. A., Norris, S. H., & Fergusen, G. D. (1988). Extensor tendon imbalance: Mallet finger, swan-neck deformity, and boutonniere deformity. In S. L. Burke, J. P. Higgins, M. A. McClinton, R. J. Saunders, & L Valdata (Eds.), Hand and upper extremity rehabilitation: A practical guide (pp ). St. Louis: Elsevier. Witherow, E., Peiris, C. (2015). Custom-made finger orthoses have fewer skin complications than prefabricated finger orthoses in management of mallet injury: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 96(10), Valdes K, Naughton N, Algar L. (2015). Conservative treatment of mallet finger: a systematic review. Journal of Hand Therapy, 28(3):237e245. Zijlstra, T. R., HeijnsdijkRouwenhorst, L., & Rasker, J. J. (2004). Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis &Rheumatism, 51(6),

33 Thank you! RALEIGH J. FINKELSTEIN HALL