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34 Rehabilitation in Congenital Hand and Forearm Defects: Rehabilitation of the Child’s Hand—General…
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34.15.1 Conservative Treatment
In this approach the rehabilitation program
begins immediately after the rst visit with the
surgeon: the sooner it occurs, even in the rst
weeks after birth, the better the chances of obtaining signicant results.
The goals are:
• Correct education of the parents concerning
the treatment to be performed at home: they
become essential to maintain and increase the
results obtained during physiotherapy
sessions.
• Keep the structures that will undergo surgery
soft, to prevent stiffness onset that could affect
the surgery itself.
• Keep the wrist, thumb (if present), and long
ngers joints mobility free
• Promote the integration of the affected upper
limb during daily life activities and games.
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The therapist sets up the rehabilitation pro-
gram together with the parents’ child, after an indepth initial evaluation and considering the
surgical timing (if dened and if needed).
It includes:
• Soft tissues manipulation and wrist stretch in
ulnar deviation: it needs to be done at least
every 2h.
• Passive mobilization of long ngers and the
thumb (if present): it needs to be done at least
every 2h.
• Circular splint with the wrist included must be
worn always except during physiotherapy and
for hygiene. The splint will be modied gradually according to the achieved results (Image
34.55).
• Stimulation of ulnar active deviation and
grasping of different objects through play.
The conservative treatment lasts till the day of
surgery or if the functional results achieved can
be considered acceptable with no surgery needed.
Image 34.55 Circular splint
34.15.2 Post-surgery Treatment
The rehabilitation program begins immediately
after surgery. The goals are dened according to
the specic indications provided by the surgeon
considering the surgical technique.
The short-term goals (0–2 weeks) are:
• Correct parents’ education to handle the operated limb.
• Edema control.
• Protection of the structure involved in
surgery.
• Maintain or increase long ngers mobility.
• Integration of the limb through games and
bimanual activities.
The therapist will pursue these goals through:
• Correct limb placement to favorite edema
control, especially during day nap and night.
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• Use of a xed circular splint with the wrist
included to maintain the alignment after centralization or a protection in thermoplastic
material above the external xator in case of
bone lengthening.
• If necessary, long ngers and thumb (if necessary) stretching both in exion and in
extension.
The mid-long-term goals (2–8 weeks) are:
• Protection of the structure involved in surgery
(Image 34.56).
• Maintain the alignment obtained through
surgery.
• Prevent scar adhesions that can affect the surgical results.
• Maintain or increase long ngers and thumb
(if present) mobility.
• Integration of the limb through games and
bimanual activities (Image 34.57).
E. M. Mancon et al.
Image 34.57 Integration of the limb through games and
bimanual activities
The rehabilitation program is structured as
follows:
• Use of a removable circular splint with the
wrist included, which will be gradually
abandoned, at the beginning during physiotherapy, hygiene, and play. It will be worn at
least for 8 weeks, after that only at night time.
• Use of a taping on the ulnar side of the wrist to
maintain centralization and as a biofeedback on
the wrist movement and muscle stimulation.
• When possible, scar treatment with massage
to prevent scar adhesions. During night the
patient uses a silicon compressive patch.
• Stretching in ulnar deviation and passive
mobilization of long ngers and thumb (if
present). In case of severe rigidity of ngers, it
is possible to make a dynamic splint to
improve MCP joint exion and a static dorsal
splint to be worn during the night to improve
extension.
• Stimulus in ulnar deviation and grasping
through games.
Image 34.56 Protection splint
Rehabilitation in patients affected by radial
cleft hand needs specic indications provided by
the surgeon according to the surgical technique
and so the program must be personalized and
well dened.
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It is essential to have continuous follow-up
during growth and check functional gesture to
analyze the results obtained and their evolution
over time; in this way it is possible to adapt the
splint and the rehabilitation program
gradually.
34.16 Psychomotor Therapy
Psychomotor therapy is a rehabilitative discipline
useful to rearrange the right balance between
motor, psychomotor, emotional, cognitive, and
neuropsychological functions, through the privileged use of game and its multiple signicances.
The Neurodevelopmental Disorders Therapist
takes on the child in all its psychophysics being,
using these tools: bodily mediation, motor and
symbolic way of playing, tonic dialogue, graphic
and physical expression, drama, and music. The
rehabilitation enhances the strong points of the
child, working on its potentialities to increase its
capabilities while understanding its limits.
The psychomotor intervention is directed
toward children in their developmental period
paying specic attention to those affected by
motor delays, coordination problems, spatial disturbances, abnormal movements, disorders of lateral dominance and muscle tone, autistic
spectrum problems, psychomotor inhibition,
neurological or psychological problems, and so
on.
In our Hand Surgery Department, the
Neurodevelopmental Disorders Therapist collaborates with the Hand Therapist to rehabilitate
children with congenital problems at the upper
limbs in their postoperative period. This kind of
rehabilitation is benecial for young patients
because it helps reintegrate the operated upper
limb into their body schema and their daily activities in a harmonic way.
The rehabilitative session takes place in a specic setting, which changes according to the age
and the characteristics of the patient. Before the
session begins, the therapist decides the use of
tools and toys to reach the target of the therapy.
Psychomotor therapy is a branch of rehabilitative medicine that deals with severe and chronic
diseases in youth. It gives value to the entirety of
the young patient, considering both the balance
and the integration of its functions and competences, and the interaction between the developmental phase and the evolution of the disease.
Psychomotor therapy considers the child as an
inseparable union between affectivity, motricity,
and cognitive structures.
Through strategies based on play, the therapist
encourages the harmonic growth of the child’s
potentialities respecting its age and personality.
In Italy, the Neurodevelopmental Disorders
Therapist supports the capabilities of each child
by creating specic and individualized plans in
an educational-precautionary dimension and in a
therapeutic one, by considering both its habilitation and rehabilitation role.
Focusing on the therapeutic aspect, the work
of the therapist is part of a complex rehabilitative
program that employs a multidisciplinary team.
In our Department the Neurodevelopmental
Disorders Therapist collaborates with hand surgeons, hand therapists (physiotherapists and
occupational therapists), psychologists, pediatric
nurses, and anesthetists.
The theoretical frame in which the
Neurodevelopmental Disorders Therapist works
is represented by the bio-psychosocial model of
disability recommended by the World Health
Organization.
The Neurodevelopmental Disorders
Therapist’s intervention area is represented by
developmental diseases such as those due to a
disease, a disturb or a known impairment, and all
other situations in which the patient has got difculties in performing, participating into, and
achieving the Growth Project.
In this Hand Surgery Department psychomotor therapy adapts itself to the children affected
by upper limb malformations to promote the use
and the participation of the upper limb while
playing in the global context.
After a surgical operation, psychomotor therapy is quickly integrated in the treatment proto-
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col respecting the surgical healing. The therapist
creates an individualized rehabilitative path
based on the problems of the patient.
The Neurodevelopmental Disorders Therapist
works with children affected by neuropsychiatric
diseases in a preventive and rehabilitative dimension in the areas of neuro-psychomotricity, neuropsychology, and developmental
psychopathology. The competence area the therapist can work with is developmental age, from
birth up to 18 years of age.
The main domains a Neurodevelopmental
Disorders Therapist works on are the following:
The Neurodevelopmental Disorders Therapist
creates an individualized rehabilitative path
based on the patient’s problems. The objectives
are based on the features of the child and the
problems shown.
The aim is reached not through a teachinglearning path, but in a communicative context, in
which the child and the therapist can exchange
and enhance their own resources.
In this Department, the therapist never loses
sight of the child’s holistic appearance and pays
close attention to how the child uses the hand
affected by the malformative condition while
playing and in the development of the physical
– Physical domain: muscle tone, motor coordi-
nation (gross motor and ne motor skills), laterality, cooperation between the upper limbs
while doing unilateral or bilateral tasks,
handwriting planning movements, and spatial
and temporal organization;
– Psychological domain: interactive skills, ver-
bal and nonverbal communication, body
image, body schema, taking initiatives, body
control, space and safety awareness, play
level;
– Intellectual domain: praxis domains, cognitive
and executive functions, self-care activities.
abilities suitable for its age. The therapist brings
the child to achieve new competences that it will
use for the rest of its life.
Starting from the observation and the assessment of the child’s global appearance, the therapist makes proposals to reach the child’s
maximum potential in daily activities (i.e., ADL,
self-care activities, school activities such as writing, cutting, and pasting, physical activities such
as riding a bicycle or playing sports, and social
integration), holding the manipulative function
in high regard. The therapist also helps improve
attention and focus, self-regulation, sensory processing, and visual perception skills.
Referring to what has just been said above,
this kind of rehabilitation is useful if the child
displays one or more problems in these domains.
In this perspective, the pathologies that can be
treated by a psychomotor intervention are several
and so different from each other that a mere list
of pathologies would not be thorough.
The children treated in this Department display upper limb malformations, obstetrical palsies, cerebral palsies, and injuries. These
conditions can be isolated or in morbidity with
other pathologies and can be the reasons why the
child does not use its body correctly or has difculties with social relationships. It is clear now
the complexity of this kind of rehabilitation.
The proposals are made by using games and
depend on the psychomotor development reached
by the patient.
“Setting” means the arrangement of the scene
in which the psychomotor takes place. The setting is the place where a person can create new
possibilities of connection with the environment
where he/she lives thanks to its physicalemotional- informational context.
The therapeutic setting is a reasoned work situation, a combination of specic general conditions
that allow to give to the Neurodevelopmental
Disorders Therapist’s actions the value of therapy.
The setting is a comfortable room that both
the therapist and the children can personalize. It
34 Rehabilitation in Congenital Hand and Forearm Defects: Rehabilitation of the Child’s Hand—General…
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must have adequate stimuli, which means that the
room must not be bare or chaotic.
This place is unrelated to the medication and it
encourages the creation of special connections
since in here the therapeutic relation is forged.
In the therapy room nothing is left to chance:
the space is set up depending on the age and the
characteristics of the patients and the targets to
achieve.
There are three kinds of setting: setting as a
physical area, setting as a mental space, and setting as a place with rules.
Firstly, the rehabilitative setting is a specic
area (the therapy room), the place in which the
Image 34.58 Setting
patient, the family, and the therapist create a
rehabilitative-therapeutic contract. Here the therapist can gather every shade of the evolutionary
process.
Environmental stability is very important.
This stability can be gained through the disposition and proposal of the objects, the safety of
the room, light regulation, thermoregulation,
and the stability-exibility of the proposals
made.
In this dimension, there is not only the room
but also the furniture (little table with chairs, the
closet, the wall bars, etc.) and the objects contained inside the room.
This place is characterized by a comfortable
and peaceful atmosphere in which the therapist,
the patient, and possible observers feel pleasure
in staying there.
The space is usually divided into two areas: a
wider zone where the patient can test its motorglobal coordination and a more dened area where
the patient can conduct ne motor activities, play
symbolic games, and relax (Image 34.58).
The objects are selected depending on the
objective that needs to be reached, the phase of
the rehabilitative path, and the capabilities of
development of the subject. They can be used
with a functional meaning or in a symbolic
wa y.
There are two main types of objects: de-
structured material and structured material.
De-structured objects can be found next to the
walls and are always available: cushions, ropes,
plastic circles, plastic canes, rubber mats, clothes,
and balls are examples of this kind of material.
They are objects that assume different functions
and aims according to the activity in which they
are employed and based on the child’s and the
therapist’s creativity.
Structured material, on the contrary, includes
objects that always have a specic function, i.e.,
puzzles, a small bed, crayons, colored pencils,
felt-tips, modeling clay, paint, musical instruments, and assembling bricks like Lego. They are
kept in a closet and employed by the therapist
only when needed.
Moreover, the setting can be thought as a mental space. The Neurodevelopmental Disorders
Therapist creates an empathic kind of relationship with the patient and builds a therapeutic alliance with the family and the caregivers. From
this perspective, the setting becomes also a meeting place: the therapist greets the patient’s efforts,
then gives them back to it in an acceptable form
with the aim to overcome the strife.
In addition, in this setting there is a normative
dimension, which is represented by all those ele-
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ments referring to the duration of the session and
the rules area.
A session lasts about 45–60min. During this
period of time, different moments follow one
another: the meeting in the waiting room, the
beginning of the session, the central part of the
session characterized by psychomotor activities
and breaks, the nal part of the session, and the
nal separation.
Finally, in this dimension there is the respect
of the rules and of the roles, which must be
respected both inside and outside the room.
Body Every child begins to organize its own
individuality through physical experiences: starting from the rst days of life, the baby communicates through the senses and the body.
In a rst moment through an impulsive and
reexed dimension, then through a practical
experimentation on it, the child begins building a
conception of an operative itself. The child recognizes its ability to behave and lays the foundations for the future self-awareness.
By growing up, the practical experiences that
the child has used so far become the basis to
catch the abstract thought (and at last to catch the
formal operative thought).
In this branch of rehabilitation, the body and
the movement have a central role because they
support and promote the global development of
the child.
Successfully developing movement, coordination, and cognitive skills is the key to children to
overcome their difculties.
Relationship The quality of the relationship
between the patient and the therapist plays an
important role in the achievement of good results
from the therapeutic path.
Since the leading channel of action in this discipline is represented by movement (not interpreted as gymnastic or sport), the relationship is
characterized by a stable balance with the child’s
physical expression.
The attention paid to the tonic dialogue during
the activities permits the therapist to keep in
touch with the patient’s needs, giving it the
chance to build an adequate emotional modulation. This element makes it easier for the children
to participate during play activities and the interaction with other people at rst during the sessions and then during its lifetime.
Play The child knows the world and grows up
while playing. For this reason, play is considered
a privileged mediator in the therapeutic relationship and permits the child to test and incentivize
its own (real and potential) abilities.
In this perspective, the therapist promotes play
activities in its multiple variances (sensorimotor,
symbolic, emotional-relational, socialization for
instance) adapting it to the individual needs and
characteristics of each child.While playing, the
child tests its own body and through the movement the child comes into contact with other people and the environment. The play is a spontaneous
activity that has the aim to produce pleasure.
Material As explained in the setting section,
the therapist uses two kinds of objects: de-structured and structured objects. The therapist offers
one or the other with different modalities during
the rehabilitative session depending on the target the therapist wants to achieve (Images 34.59
and 34.60).
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Images 34.59 and 34.60 Therapist’s activity
34.17 Pediatric Hand Trauma
A trauma can be for an adult a sudden change of
status, the patient is immediately more help from
caregivers and the same is for children. Everyday
life can change temporarily or denitively, and
the child needs help and attention to accept this
new status of his/her upper limb.
The trauma often modies our motor image,
and the little patient needs to adapt to this new
functional or aesthetic situation and this can be
hard for the child and his family. Sometimes children focus on their difference or limitation so
much that this aspect becomes the most important feature of their bodies.
Emotionally children are ashamed and desire
to hide the hand, they try to put the hand in the
pockets, sometimes they do not want to wear
T-shirts, or they avoid public situation like school
and playground.
One of the rst health workers that the family
has to deal with is the hand surgeon, for a decision plan of therapy.
A good relationship with the health workers
can increase the satisfaction of the patient and
of caregivers, and this can be useful and positive also for the psychological aspect of acceptance of the new situation, this also helps to
increase the compliance of the patient and of
the family.
When is necessary or request a psychological
support is given to the child and family, together
or separately, this can help both to express the
expectations and realize the real possibilities and
abilities that the child will have at the end of the
surgical treatment and rehabilitation.
After the surgery the limb of the little patient
is protected by a bandage; often the dressing covers also some healthy segments, and this can contribute to an inappropriate and miraculous image
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of the hand. However this is necessary to protect
properly the limb after the surgical approach.
The post-surgery period is a lapse of time in
which the little patient and family have the
chance to deal with anxiety, and loss of the total
control of the usual status of heath we all have
in everyday life. This is the time of rehabilitation; the patient starts to get used to: be touched
by the therapist’s hands, to see the injured segment and the whole hand or arm. During the
physical therapy it is very important for the
patient to have a high compliance, because it
plays an important role in it. The aim of the
therapist is to rehabilitate the whole limb
through games and playing with children.
Rehabilitation can be very difcult for pediatric
patients, much more than with adults, especially
for very traumatic accidents.
It can be very hard to obtain a high level of
compliance for the whole section of physical
therapy; in fact children can be shy, or worried or
even terried sometimes; this is why the therapist
needs to be patient, especially if some particular
movements are required for the situation. Often a
good observation of the child, respecting the
motor milestones and the cognitive growth, can
be the key for a good rehabilitation, and also
often change games and toys, choosing something appropriate for the aim of the physiotherapy but fun in the meantime is essential.
The younger is the child the easier is for him
to adapt to new situations; the same works with
neuroplasticity: with a good rehabilitative plan, a
good relationship between the little patient and
the therapist, the child will be able to regain dexterity and good motor skills, and this means good
functionality and quality of life.
34.17.1 Fractures
Over 25% of traumas in pediatrics are fractures:
in particular in the early stages of age crushing
traumas often occur, and adolescents often injure
themselves while they are playing or doing
sports.
In crushing traumas distal phalanges and
external rays of the hand are often involved.
Interphalangeal joint traumas and volar plate
lesions are also quite common.
All muscular-skeletal injuries have a different
evolution in children compared to the same injury
on an adult; in fact the elasticity of the different
tissues and the presence of the growth plate need
a different therapeutic approach.
Particularly the surgeon will pay attention to
the possibility of interfering with the correct
growth of the limb or segment, or having distal
problems on nerves, or lately with secondary
arthritis, stiffness, or chronic pain.
Bones in children can change quite quickly in
shape, rotation, and alignment, if they are subjected to stress.
Many fractures of the hand and wrist in children can be treated in a conservative way, with a
cast or splint, and do not need surgery.
34.17.1.1 Conservative Treatment
Immobilization needs to be done immediately
after the reduction of the fracture, particularly if
the little patient is under anesthesia. A cast is
probably the better choice for children, casts in
fact are very resistant, and often the immobilization is wider than it should be for adults: for
example in a very young patient with a fracture of
a phalange it is necessary to include the wrist too.
If the cast is small or light the risk is that the child
can be able to remove it or damage while he plays
or sleeps.
In compound fractures normally the treatment
is cast immobilization for 3/4 weeks and then a
visit after an X-ray, when the cast is taken off a
removal splint is made by the therapists. During
the following days a specic rehabilitative with a
hand therapist begins.
34.17.1.2 Surgical Treatment
Surgery in pediatrics is very different from surgery in adults: the periosteum is thick, growth
plates are delicate, so the surgeon has to pay
attention during the whole surgical approach.
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34.17.2 Apical Traumas:
Rehabilitative Part
In pediatrics distal phalangeal traumas are quite
common; crushing traumas represent the most of
apical traumas, but also hyperexion or
hyperextension.
Crushing can generate lesions of the nail or
sub-nail hematoma, or more complex trauma like
complete lesion of the nail bed, fracture of the
distal phalanx, or a lesion of the exure or extension tendon.
In case of surgical ap suture also with microfractures after 4 weeks with a xed digital splint
(Image 34.61).
The patient can start the active mobilization
with a selective recruitment of the exor digitorum profundus, exercises for the recruitment of
extensor tendons. When the wound will be completely healed, the therapist can begin the treatment of the scar with a hydrating cream and with
the use of a silicone elastomer during the night
(Image 34.62), associated with a CoBan bandage
Image 34.62 Compression
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Image 34.61 Digital splint
to give to the nger the correct compression for a
proper skin remodeling.
The therapist will teach the parents how to do
exercises for sensibility in order to manage the
alteration of sensibility that is completely normal
in this situation; this can help a quicker recovery
and a quicker corticalization.
A digital and removable splint will be used
during the night and in risky situations like
schools and playgrounds until 8 weeks from the
surgery.
In case of sub-amputation of the distal phalanx the postoperative period will be of immobilization with a digital splint in protection of the
amputation stump (Image 34.61).
When all the wounds are completely healed,
the hand therapist will make a removable splint in
order to protect the stump, the parents will be
taught how to massage the scars and the use of
silicon sheets will be suggested for the night.
Also in this case sensibility has to be stimulated
through different tissues. It is very important that
the little patient at the end of the therapy is able to
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are not directly involved in the trauma, with the
aim of give more stability and to be safer (Image
34.64a, b).
The time of immobilization is on average longer than in adults; for example in the lesion of
exor tendons we begin physiotherapy at the end
of the fourth week keeping the splint that will be
made removable, with the wrist extended 0^-20,
metacarpal-phalangeal joint at about 30^, and
interphalangeal joint extended (Image 34.65a, b).
ab
Image 34.63 Example of manual activity
use the ngers involved in the trauma for all the
activities of daily living (Image 34.63).
34.17.3 Tendon Lesions
inPediatrics
Tendon lesions in children have a high incidence
because they explore the world outside with their
little hands often without paying attention. If
these lesions are not treated properly they can
cause important functional decits and decits of
growth; the child in fact can learn daily activities
with the complete exclusion of the segment or of
the whole hand.
However it is very difcult to treat children
with this kind of lesions because sometimes they
have a very low compliance and little hands and
little ngers are very difcult to treat and to
splint.
The major difference between the treatment of
an adult and a child in this eld is that treating a
child means a bigger immobilization and bigger
splints that can include also did it and joint that
Image 34.64 (a, b) Immobilization in pediatric tendon
lesions
ab
Image 34.65 (a, b) Removable splint
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