Hand Therapy Review Course Curtis National Hand Center Baltimore, MD October 7 9, 2016 Fractures Rebecca J Saunders PT/CHT Epiphysis Physis Metaphysis Diaphysis Periosteum Endosteum Cortical bone compact bone Concentrated in diaphysis of long bone Houses osteons (contain osteocytes) 80% of skeletal mass Cancellous bone trabecular or spongy) 20% skeletal mass Concentrated at epiphysis and metaphysis of long bones Metabolic turnover is greater than for cortical; usually faster healing Energy absorbed by bone mechanical & structural failure Loss of Continuity of Bone vascular disruption at fracture site soft tissue injury Location in Bone Diaphyseal Metaphyseal Articular
Depth of fracture: complete, incomplete Angle: transverse, oblique, spiral, longitudinal, Complexity: simple, comminuted or crushed Closed versus Open Intra articular vs. extra articular Avulsion Inflammatory Phase (0-2 weeks) Accumulation of a hematoma between fracture ends under elevated periosteum Bone necrosis (osteocytes lose nutrition) Proliferation of fibroblasts and osteoblasts Invasion of leukocytes and macrophages Hematoma organizes forming fibrin scaffold External carilagenous callous forms from periosteum Internal callous forms from endosteum Gradual increase in stability toward clinical union New bone and oteogenic cells bridge fracture site Occurs over prolonged period of time Process of continuous bone resorption and formation Bone is remodeled as oteoclasts reabsorb callous Can be influenced by stress Primary Healing: No Callus formation Direct apposition of bone ends with compression Rigid fixation (substitute for callus) Secondary Healing: Callus formation Slight movement /micromotion
Patient s age Complexity/Character of fracture Systemic Disease Bone Disease/metabolic bone disease Medications Nutritional factors, ETOH, tobacco use Nicotine has detrimental effects on the health of bone Has deleterious effects on blood vessels and the transport of O2 to body cells Decreases red blood cell function Higher nonunion, delayed union rates Higher rates of postop infection Compliance Emotional status Other injuries: tendon, nerve, soft tissue, multiple fx s Buckle or Torus fracture (incomplete fracture) Greenstick fracture Physeal fractures Joint stability Infections Salter I separation through growth plate (physis) Salter II injury through physis with part of metaphysis attached Greenstick fractures occur midshaft where bone is slower to heal Require 6 wks of cast immobilization Salter III injury thru physis; longitudinal fracture thru epiphysis
Salter IV longitudinal fx extending into metaphysis,physis,epiphysis; complete reduction necessary to restore joint surfaces Salter V crush injury to germinal cells of physis; premature closure of growth plate This cast won t slow me down! Angular deformities better tolerated in children, greater capacity for remodeling as bone grows Cast/splint may need to include more proximal joints to keep cast on Stability Mobility Function Therapists should have understanding of: Fracture stability/alignment Operative procedures performed Potential dysfunction at uninvolved joints Appropriate timing for ROM, splinting, strengthening Balancing act between protection and applying controlled stress for motion and strength ***Motion or stress to the bone promotes bone healing. Edema control Pain management Protection AROM PROM Sensory eval and desens. Functional activities Strengthening Closed Reduction Indication= stable fracture Immobilized with cast or splint What s wrong with this cast?
External Fixationprovides traction to prevent fx. shortening or angulation Indications unstable fx s fx s requiring early motion fx s w/ high incidence of nonunion K-wires: open vs. closed Screws Plates Wires Intermedulary Nails Bone Grafts Soft tissue injury Periosteal stripping Hardware irritation Adhesions Tendon Ruptures Non union Malunion/Bone length alteration Delayed union Edema Pain Stiff joint Tendon adhesions Decreased strength Nerve entrapments or compressions Post-traumatic OA What s wrong with the xray at 6 weeks? 6 P s: Pain, paresthesia, pallor, paralysis, pulselessness, pressure
Colles Extra-articular Complete fx. of distal radius w/ dorsal displacement 80% require reduction Colles fractures often do not stay reduced and need surgery to maintain alignment. Smith s: Reverse Colles fracture Distal radius with volar displacement Barton s: Distal radius fracture with dislocation of radial carpal joint. Rim of distal radius fracture with volar or dorsal displacement Oblique fx of distal radius involving radial styloid Intra-articular fx Generally require surgery Stiffness, swelling, pain Malunion/radial shortening DRUJ dysfunction RSD/CRPS Median nerve compression Radiocarpal arthritis Weakness Carpal instability Shoulder stiffness Watch for substitution of EDC when attempting to perform wrist ext
Teach patient isolated wrist extension to learn to control EDC substitution Initiate blocking exercises early especially FPL which can be adherent Inability to flex IP during oppostion indicates FPL adherence EDEMA CONTROL Splinting for stability and protection Motion Modalities Pain management-watch for increased sympathetic reaction, TENS Function Strengthening FES mm. weakness and retraining Dynamic splinting Work simulation/hardening Activity Modification
One month post injury: resting position of hand with 25 degrees UD. Final numbers Pro/Sup: 15/60 50/75 Ext/flex: 40/45 65/60 RD/UD: 35/20 15/30 4 Weeks Post Op: Splint A/AAROM Scar management 6 weeks post op: strengthening Occur 1/10th as frequently as distal radius fractures Scaphoid: account for 60-70% Triquetrum/Lunate : second most common- account for 20% Others: combined account for only 7-10% of fx 90% occur from force applied with wrist in extension (FOOSH) Vulnerable to injury position in both proximal and distal rows Difficult to diagnose - often made based on clinical signs Pain in snuff box Variable healing times according to fracture site
5-20+ weeks depending on level Middle 2/3 10-12 weeks poor vascular supply Proximal Direction of 12+ fracture weeks 1/3 affects healinghorizontal quicker than vertical Non- union Carpal ligament injuries Carpal instability Delayed diagnosis Normal anatomical alignment not restored Persistent pain SLAC wrist SLAC Wrist S scaphoid L lunate A advanced C collapse Triquetrum: 2 nd most common. FOOSH Lunate: Can result in avascular necrosis (Kienbocks disease) Trapezium: often associated with fractures/dislocations involving thumb Pisiform/Hamate: trauma over ulnar/volar wrist, proximal hypothenar eminence Capitate: rare because this carpal is in a centrally located and protected position Trapezoid: rare; crush or high energy impact Focus on wrist and thumb ROM, and composite flexion May require protective splint between exercise post cast removal Functional ADL s encouraged
Static progressive or dynamic splinting for wrist flexion and extension or composite motion Grip strengthening Wrist strengthening within pain free range Work hardening depending on RTW status Quick healing Occur more commonly in the border digits Degree of angular deformity accepted varies for each ray Complications of angulation are extensor lag and decreased grip strength Some degree of angular deformity is acceptable Rotatory deformity ie: fingers overlapping (scissoring) is not acceptable This check is used for phalangeal fractures also MP s need to be immobilized in flexion to maintain collateral ligament length Goal is to achieve alignment without rotation or shortening Shortening of 3-5 mm can produce imbalance intrinsic/extrinsic Malrotation= finger overlap Angulation tolerated better in 4/5th MC
MC fx s can result in soft tissue damage Often excessive dorsal edema Common because less soft tissue between extensors and MC s Result in MCP extension lags and extrinsic extensor tendon tightness Treatment: isolated EDC exercises, scar massage, FES, combined wrist/finger flexion, other modalities MP joint contractures can occur following metacarpal head and neck fractures Proper positioning in splint crucial, at least 60⁰ MP flexion; if unable to obtain correct position readjust in a few days Hand Fractures can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness from poor treatment Alfred Swanson Type varies Oblique, transverse, spiral Spiral/oblique tend to be unstable Often cause soft tissue adherence Comminution = more soft tissue damage
PIP flexion contracture Limited active PIP extension Tendon adherence at fx site Edema control Splinting Hand based Buddy taping Motion: AROM AAROM Once Healed PROM/dynamic splinting Functional activities Strengthening Can start motion earlier due to stability of fixation Addition of scar management Soft tissue involvement Account for 50% finger fractures Thumb/middle most commonly injured Crush common mechanism of injury Classified by location Heal w/out excessive treatment Crush/ comminuted fx of fingertip Painfulhematoma Soft tissue injury Rehab: Restore DIP motion Desensitization Protective splinting to DIP
Extensor tendon avulsion fx or dorsal intraarticular fx Flexion drop deformity Tx: Mallet splint Slight hyperextension A/PROM to MP/PIP Splinting in extension for 6-8 weeks is standard. Once healed/stable may begin DIP flex Continue splint use between exercise and at night Watch for extensor lag with exercise (resume splint use if lag increases) Resume motion and normal activities. Numbness Hypersensitivity or tenderness Cold intolerance Limited DIP ROM Nail abnormalities Follows similar guidelines as for digits Special considerations: Thumb joints can lose motion faster than in fingers Motion at basal joint helps when MP joint motion is lost Prevent 1 st webspace contracture Bennett Fracture: Most frequent Fracture dislocation at CMC Oblique intra-articular metacarpal fx Rolando Fracture: 3 part intra-articular fracture at base of metacarpal
Clam shell splint: include MP and exclude IP joints AROM (gentle) of IP joints Edema control 6 Weeks: started MP AROM/AAROM 8 Weeks: d/c splint and begin light strengthening. AROM IF MP: 15/60 PIP: 5/85 LF MP: 10/75 PIP: 10/85 R L Lat pinch: 11 13.5 Tripod: 12.5 11.5 Grip: 33 38 Shortened IF metacarpal with dorsal angulation. Slade,J, MD, et al, (eds), Hand Clinics: Scaphoid Fractures, Volume 17, No. 4, November 2001 Berger,R et al, (eds), Hand Clinics: External Fixation, Philadelphia, WB Saunders, Volume 9, No. 4, November 1993 Freeland A, Lindley, S, (eds), Hand Clinics: Hand Fractures and Dislocations, Philadelphia, WB Saunders, Volume 22, No. 3, August 2006. Fischgrund, J, (ed), Orthopaedic Knowledge Update, Chapter 2, Fracture Repair and Bone Grafting, AAOS, 2008, pgs 13-19. LaStayo, P, Winters, K, et al, Fracture Healing: Bone Healing, Fracture Management, and Current Concepts Related to the hand. Journal of Hand Therapy 2003; 16(2): 81-92 Cannon N: Rehabilitation Approaches for Distal and Middle Phalanx Fractures of the Hand. Journal of Hand Therapy 2003; 16(2): 105-116 Seu,M, Pasqualette,M :Hand Therapy for Dysfunction of the Intrinsic Muscles:, Hand Clin 28 (2012) 87 100 Kollitz M, Hammert WC et al: Metacarpal fractures: treatment and complications HAND (2014) 9:16 23 Sammer DM, Husain T, Ramirez R:Selection of Appropriate Treatment Options for Hand Fractures, Hand Clin 29 (2013) 501 505 Neumeister M et al: Non-surgical Management of Metacarpal Fractures Clin Plastic Surg 41 2014 p451-461 Suh N et al: Carpal Fractures J Hand Surg Am 2014, 39 (4) 785-791 Lalonde D et al: Pain Guided Hand Therapy for Hand Fractures: the Saint John Protocol: contact Amanda Higgins at grashay@nb.sympatico.ca for a digital copy of the protocol. Feehan, L, Early Controlled Mobilization of Potentially Unstable Extraarticular Hand Fractures. Journal of Hand Therapy 2003; 16(2): 161-170 A specialist knows the worst mistakes which can be made in his field and how best to avoid them - Nils Bohr