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Figure 19.
A
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Joint Blocking Exercises
A
B
C
A, e patient blocks the proximal interphalangeal
joint while exing the distal interphalangeal joint
isolating exor digitorum profundus tendon glide. B,
Same as A, but to minimize resistance to the exor
digitorum profundus tendon, pressure can be applied
over the radial and ulnar sides of the middle phalanx,
rather than on the volar surface. C, e patient holds
the ngers adjacent to the involved nger in extension; the patient exes the proximal interphalangeal
joint isolating exor digitorum supercialis tendon
gliding.
as necessary to improve composite exion and add light resistance around 8 weeks post-repair. If muscle-tendon unit shortening is a problem, the patient wears an orthosis that positions
the ngers and wrist in extension providing a low-load long-du-
ration stretch. However, the patient does not begin heavy (>10
lbs) resisted activities until 10 to 12 weeks post-repair.
88
In most cases, surgeons and therapists prefer early, protected mobilization protocols. ese include early passive and early
active protocols. Considering the increased force required for
active nger exion caused from postoperative edema, versus
the strength of the repair, practitioners generally recommend
waiting 3 to 5 days to begin exercise, although the optimal
79
timing for initiating therapy is not known.
Cannon88 recommends 3 to 5 days with 5 being her ideal for a patient to be
removed from the postoperative dressings and starting rehabilitation. Patients are typically placed in a protective wrist/hand
dorsal blocking orthosis. Although the position varies, typically
the wrist is in slight exion or neutral and will be modied to a
slight extension position over the following weeks of protection.
Some protocols will allow for wrist motion in a tenodesis manner by releasing the distal straps of the orthosis, or the orthosis
may be designed with a wrist hinge. e ngers are in an intrinsic plus posture (MP joints exed 70° to 90° and IP joints in full
extension) allowing the repaired exor tendons to be on slack
while at rest. Full IP joint extension may not be immediately
obtained if the tendon was repaired under tension, requiring to
make full or near full IP joint extension an early goal of therapy. Knowing that motion of the tendon is our early goal yet
wanting to minimize the friction and load to the structure, it
is important to address edema of each digit and stiness in the
nger joints prior to performing active tendon glide.
Patients are therefore started on passive DIP and PIP joints
exion with active extension of the same joints at this rst visit.
Passive individual joint motion is performed rst, followed by
composite passive nger exion within each patient’s tolerance.
Self-adhered compression wrap or a gauze circumferential wrap
88
may be used as needed for edema control.
Cao and Tang95 in
an in vitro study noted the increase of force needed to create
tendon glide in a digit with minimal, moderate, or severe edema. e additional force required to create tendon glide was
1.7, 7, and 9 N, respectively. Appreciating the signicance of
the greater force needed during active exion requires the therapist to delay active motion in the presence of edema, continuing
with passive motion while aggressively addressing the edema as
needed.
Active tendon glide may be started on this rst or the second visit once improved ease of passive motion is obtained.
Most protocols encourage a program of passive IP joint exion
and active IP joint extension with the MP joints remaining in
a position of exion (50° or greater). Note that it is important
to teach each patient to work on active IP joint extension as
the tendency is to develop a PIP exion contracture as healing
progresses. Because the tendon is on slack by the wrist and MP
joint positions in the orthosis, typically, full PIP motion may be
obtained with active extension in the connes of the orthosis. If
not, it is important to have the patient come out of the orthosis
to work on PIP extension while the MP joints remain exed.
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35
Once active motion is initiated, the goal is to achieve ap-
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proximately a half composite st actively 10 times each waking
hour. is motion increases the chance that tendon glide can be
maintained prior to the development of signicant adhesions.
By not performing a full st or resisted activities, the exercises
remain in the load range that multi-strand repairs can withstand. is encourages adequate load onto the tendon to overcome friction but not overload the strength of the repair. Please
note that the value of the place-hold exercise, where the ngers
are passively placed in exion and then the patient asked to ac-
25
tively hold the position, is being questioned by some.
ere is
evidence that the tendon may “bunch” with the passive IP joint
exion and then be jerked through a pulley on the active hold.
is is considered a questionable amount of sudden force onto
the core suture with the possible outcome of gap formation at
the repair site. Place-hold is still described in some protocols as
an early motion option, but you should be judicious about its
use in a home program.
e focus of the rehabilitation from weeks 1 to 3 continues with the above exercises. Exercises may be completed out
of the orthosis if the patient understands and is compliant with
the precautions. A suggested exercise to increase muscle tendon excursion is passive IP joints exion starting with the wrist
in exion and maintaining the IP joints in exion as the wrist
is moved into extension. e ngers are passively held in the
exed posture through the wrist motion. From weeks 3 to 6,
additional exercises may include combined wrist tenodesis and
nger motion. Active exion exercises progress from the halfst toward a full st. Extension position of the MP joint when
performing the exercises is progressed incrementally. Interventions for scar and edema control are used as needed. Range of
motion measurement allows regular but small improvements to
be documented. Most protocols discontinue the use of a protective orthosis at 6 weeks. is allows initiating recovery of full
MP and IP joints extension. Dierential tendon glide may be
used at this point if not already begun. Light ADLs are typically
tolerated at this point. Resistance exercises may begin 8 weeks
post-surgery. Return to work, even for manual laborers, can occur by about 12 weeks.
Most rehabilitation protocols suggest that similar activities should be followed for exor tendon repairs in other zones.
Zone I injuries, by denition, only involve the FDP tendon. A
soft tissue repair, whether the tendon was lacerated or avulsed
(jersey nger), can follow the same rehabilitation protocol as
described above. A zone I injury that includes a signicant bony
avulsion (a Type III jersey nger) may be treated as a fracture
with surgical xation of the avulsed bone to the distal phalanx
followed by a period of immobilization. Repairs in the proximal
zones III to V do not have the same concerns about tendon
gliding in the bro-osseous tunnels or restrictions at the pulley
levels, therefore, making positive outcomes here more reliable.
25
Multiple tendons repair in zone V (area proximal to the wrist
crease) often results in signicant scarring among the tendons,
which may limit tendon excursion and ultimately ngers or
wrist motions. Early active glide exercises in zone V injuries
can be helpful. Zone V lacerations also often involve injuries
of the local neurovascular structures, potentially complicating
the recovery process. For those treating exor tendon repairs,
the book chapter by Cannon titled, erapy Management of
Flexor Tendon Injuries and Repairs, provides specic protocol information, images of dierent options for orthosis design, and
additional examples of exercises that may be used through a
88
progressive program.
Excellent communication between therapist and surgeon
is necessary to choose the most appropriate protocol for the
patient. Progression of the rehabilitation program is based on
science, but is also truly an art. Many patients cannot follow a
strict protocol and may need an individualized program, with
96
changes being made at each visit. Morrell et al
in their publication emphasized the benet of the team approach with all
involved to maximize outcomes with this patient population.
Extensor tendons
e extensor tendons are divided into 8 zones of injury
(Figure 20). Common injuries of the extensor mechanism include the mallet nger disruption in zone I. As noted in the
upcoming section on fractures, this injury may be a soft tissue
avulsion, or involve a piece of bone from the distal phalanx.
Injuries across the middle phalanx or PIP joint (zones II and III)
can aect the conjoined central slip of the ED and/or the lateral bands. Whether treated nonsurgically or following surgical
repair, adequate healing of the extensor mechanism is important before full motion is allowed across the PIP joint; although
early movement through a limited ROM arc is often used and
is described later. An injury to the extensor tendons in zones V
through VIII generally requires a period of immobilization in a
protected position but, when possible, limited short arc motion
may begin prior to the development of restrictive adhesions. Injuries involving the dorsal hood, periosteum, or the bone itself
may interfere with a successful outcome due to scarring between
these adjacent tissues. Extensor tendon adhesions can severely limit function as composite sting requires more excursion
from the extensor tendons than the exor tendons due to the
greater circumference they must traverse over the metacarpal
heads. Motion started too early or performed through too great
of an arc of motion can gap the repair and create an extensor lag.
Zone I, or mallet injuries, can result from an aggressive action which forced the DIP joint into exion resulting in the soft
tissue avulsion of the terminal tendon from the distal phalanx.
Radiographs should be completed to rule out bony involvement
and to determine if the DIP joint surface is aected. Please refer
to the section on nger fractures for more information on bony
mallet injuries. A soft-tissue mallet injury should be treated
with a full-time aluminum foam or thermoplastic orthosis with
the DIP joint in full extension. Hyperextension of the DIP joint
97
is not recommended due to potential dorsal skin necrosis.
36
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For personal use only. No other uses without permission.
Figure 20.
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Zones of Extensor Tendon Injury
Zone I: distal interphalangeal joint; zone II: middle
phalanx; zone III: proximal interphalangeal joint;
zone IV: proximal phalanx; zone V: metacarpophalangeal joint; zone VI: dorsal surface of the hand; zone
VII: dorsal surface of wrist joint; zone VIII: dorsal
surface of forearm, proximal to the wrist joint; zone
TI: thumb distal phalanx and interphalangeal joint;
zone TII: thumb proximal phalanx; zone TIII: thumb
metacarpophalangeal joint; zone TIV: dorsum of the
thumb metacarpal.
During the immobilization period (6 to 8 weeks), none of the
other nger joints, including the PIP joint, should be immobilized. Full-time DIP joint extension is key even when performing changes of the orthosis and skin checks. Following immobilization, motion into exion should be initiated incrementally
(ie, week 1 post-immobilization 20-25° of exion allowed, week
2 up to 35° of exion allowed, etc); however, if an extensor
lag develops, orthosis use is re-started and motion is delayed
98
for a few more weeks.
Roh et al99 reported that extensor lags
(and therefore poorer outcomes and patient satisfaction) were
associated with increased age, poor patient compliance, and low
health literacy. A chronic mallet nger deformity can lead to
the development of a swan-neck deformity (PIP joint hyperex-
tension and DIP joint exion). Individuals with ligament laxity
and with natural mobility into passive hyperextension of the
PIP joint are more at risk for a swan-neck deformity following a
97
chronic mallet nger injury.
Acute injuries in zones III and IV can occur secondary to
closed injury, such as a PIP joint dislocation, or an open injury such as a laceration. ese injuries may disrupt some or
all contributors to the extensor hood (Figure 5). Disruptions
involving the triangular ligament, the lateral bands, and/or the
central slip can allow the lateral bands to migrate toward the
palm until they are volar to the PIP joint axis of rotation, where
they become exors rather than extensors. e loss of balance
between the exors and extensors can result in a Boutonnière
100
deformity.
Treatment of a closed tendon injury at zone III
or IV includes using a PIP joint extension orthosis (aluminum
foam or custom thermoplastic) on the dorsal surface of the nger with the DIP joint free to move. e patient uses the orthosis at all times for 6 weeks for complete ruptures and 3 weeks for
101
partial ruptures.
Surgeons manage open injuries, or lacerations, through primary surgical repair. Post-surgery, individuals
with combined repairs of the central slip and lateral bands are
immobilized with both the DIP and PIP joints in extension for
98
6 weeks.
But, the therapist may encourage early active shortarc motion in a range of 0-30° for the PIP joint and 0-25° for
the DIP joint in this rst week, although full IP joints extension
should be maintained when not exercising. If the lateral bands
have not been repaired, the above active short-arc motion is
completed at the PIP joint and isolated active DIP joint motion
may be performed through an unlimited range. Care is taken to
minimize the load to the extensor tendon by exing the wrist to
30° during the short-arc motion exercises, decreasing the tension forces of the extrinsic exors at the PIP joint during active extension. is limited motion is performed every 2 hours
throughout the day, but the patient returns to complete PIP and
DIP joints extension in the orthosis when not exercising. If no
extension lag develops, each week the arc of motion is increased
98
by approximately 10°. Evans
notes that by week 4, the average
PIP joint is moving actively 60-70°, and by week 6 near normal
extension (-3°) to 88° of exion is achieved. e short-arc motion exercises are best performed with 2 custom thermoplastic
orthoses to guide the patient to the desired amount of exion
and to perform independent DIP joint exion while protecting
98
the PIP joint during the home exercises.
e patient performs
MP and wrist joint active motions daily while the PIP and DIP
joints are immobilized. A gentle strengthening program begins
at 6 weeks post-surgery.
Surgeons manage zones V and VI injuries with primary
repair. Patients may be immobilized for 4 to 6 weeks after surgery, but like other zones there is evidence of increased eorts
required to recover joint motion and tendon excursion after
immobilization compared to those started on early motion pro-
102
grams.
Researchers calculated the amount of motion that is
helpful for tendon nutrition. Safe active or passive movement
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37
at the MP joints of the index and long ngers is from slight
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hyperextension to 30-45° of exion and for the ring and small
103
ngers, slight hyperextension to 40-50° of exion.
is is
enough movement to allow the positive eects of stress between
the repaired tissues and the surrounding anatomy without attenuating the repair. e IP joints can be mobilized through full
active and passive exion without compromising a zone V or VI
repair if the wrist and MP joints are held in extension during
98
the PIP and DIP joints ROM exercises. Evans
advocates the
use of a dynamic custom orthosis in the rst week holding the
wrist in slight extension, allowing graded active motion of the
MP joints into exion with passive or active assisted return to
extension. e authors of this monograph have had success with
the use of a static orthosis (wrist neutral to 20° of extension,
MP joints in full extension to slight hyperextension, and the
IP joints slightly exed) between exercise sessions with removal of the orthosis for exercises that include carefully instructed
active exion and active assistive extension of the MP joints.
e wrist should be in a position of 20° of exion during the
active assisted MP joint extension exercises to minimize resistance from the antagonistic nger exors. e active assistive
extension is performed by the patient’s opposite hand. As the IP
joints are in the static orthosis at least for the rst 4 weeks, active IP joint exion and extension with the MP joints manually
supported is also encouraged during each exercise session. At 4
weeks post-surgery, the orthosis may be altered to allow the IP
joints to be free while maintaining support of the wrist and MP
joints. Guiding the patient with careful instruction in the allowed ROM and screening the patient for the ability to comply
with the home exercise program will improve outcomes. e
protective orthosis is typically removed at week 6. e therapist
instructs the patient to discontinue composite exion if an extensor lag appears. Of note, Merritt et al
104
and Howell et al
105
have used a unique static orthosis (a relative extension orthosis)
to treat an extensor tendon repair to a single digit. is is a small
hand-based static orthosis that mildly hyperextends the aected digit compared to the neighboring digits. Using this design,
they have used an immediate controlled active motion program
for many years.
98
Zone VII (dorsal wrist) injuries are particularly problematic. Scar formation between the tendon, tendon sheath, and
dorsal retinaculum can limit wrist and nger exion and extension motion and limit functional activities. After a zone VII
primary repair, some surgeons prefer immobilization protocols.
e therapist uses an orthosis to position both the wrist and the
MP joints in extension for 3 to 4 weeks. e patient should not
actively extend the PIP joints with the wrist and MP joints in
extension due to the greatly increased force needed to extend
in that position. Passive or active extension of the PIP joints is
completed when the wrist is in neutral or is slightly exed.
With early motion programs for zone VII injuries, the
therapist may use a dynamic orthosis that allows the patient to
ex the ngers actively while elastic bands assist the MP joints
into extension. In this manner, motion can be started early yet
minimal force is generated through the repair site. Other protocols may not use a dynamic orthosis, but rather begin motion
when an active assistive program of wrist and nger tenodesis
action can be safely performed. A static orthosis for tendon repair at this level should place the wrist in 35-45° of extension
and the MP and IP joints at 0°. Exercises should allow progressive wrist motion toward 10-20° of wrist exion, but less will
be allowed if wrist extensors were also repaired. If more than 1
tendon of the ED has been repaired, dierential extensor tendon gliding is helpful to minimize adhesion formation between
tendons. is is performed by actively moving 1 nger at a time
into exion while holding the others in extension. e long and
ring nger tendons are interconnected at the wrist and therefore
98
may move together.
During the rst 3 weeks, with the wrist
extended, the patient may actively ex the MP joints 30-40°,
progressing to 40-60° by week 4, and 70-80° by week 5. In the
fourth week, the patient begins gentle wrist exion with 50%
composite nger exion, progressing to complete wrist exion
plus composite nger exion by week 6 as the patient weans
away from the orthosis.
Tenolysis
Tenolysis is the surgical removal of adhesions limiting tendon excursion that have formed after exor or extensor tendon
repair. is procedure also carries potential complications such
as tendon rupture, further degradation of the neurovascular system, and possibly worsening symptoms and functional abilities.
Tenolysis might be considered when there are no improvements
in ROM after 3 months of adequate therapy. Before performing
this procedure, the patient’s passive motion must be within a
functional range and greater than what they can achieve actively, and there should be evidence that soft tissue scar production
has stabilized. Patient selection is the key to success. A patient
should have full PROM of the involved nger(s) and be strongly motivated and willing to participate in the intensive therapy
program that follows surgery. e strength of the extrinsic exors should also be a consideration prior to the surgery. Patients
should be instructed that they will need to commit to therapy
and a time-intensive home program to maximize the benets
of surgery.
After exor tenolysis, when tendon integrity is good, the
therapist initiates AROM immediately (Day 1) and, when possible, sees the patient daily for the rst 5 days. Treatment consists of AROM, PROM, pain management, edema control, orthosis positioning, and instructions regarding a home program.
Recovering active tendon glide is key to long-term success and
providing patients frequent feedback can be extremely helpful
in the progression of the home exercise program. A functional
resting orthosis is used early on to help reduce the inammatory
process and provide a comfortable resting posture between exercise sessions. Trumble
97
recommends hourly repetitions of active
nger exion in Days 1 to 3. Passive motion may be performed
38
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For personal use only. No other uses without permission.
to negate the eects of joint stiness, but active tendon glide is
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the major goal. In weeks 1 to 6, the exercises are progressed to
include dierential glide of FDS and FDP tendons if necessary
and initiate a slow recovery of light functional ADLs. Orthoses
to minimize the development of joint contractures may be used
in the early postoperative period as needed. A patient may perform place-and-hold and 4-stage tendon gliding exercises the
rst week (Figure 10). e therapist adds joint blocking exercises 2 weeks after surgery (Figure 19). At 6 weeks, the therapist
may initiate gentle resistance activities with progressive resistance activities beginning at week 8. When tendon integrity is
poor, the patient may only perform gentle active assisted exion
exercises to a half-st position during the rst postoperative
week and active motion would start in the second week. It is
important to communicate with the surgeon to determine safe
early phase exercises. e same principles outlined above can be
used for an extensor tenolysis. Care must be used to not work
on composite exion too early to avoid the development of an
extensor lag. Also, rehabilitation must not focus on gaining exion at the expense of recovering active extension.
Fractures and Joint Injuries
Hand fractures
Hand fractures are evaluated with respect to their location
(which bone and what location on that bone), orientation of
the fracture line, displacement, angulation, rotation, extent of
comminution, and any associated joint involvement or dislocation. Stiness of 1 or more joints following phalangeal and
metacarpal fractures is very common and can be dicult to
treat. Stiness sounds relatively innocuous, but found in the
small joints of the digits after trauma, this impairment may be
more dicult to treat than malunion, nonunion, and arthrosis combined.
fractures, Cheah and Yao
14
In a current concepts article dedicated to hand
106
noted trends towards minimally invasive surgery and early mobilization, yet recognized that early
motion can lead to fracture malunion or nonunion. e therapist must be attentive to the protection of the injured structure
yet encourage mobility of uninvolved areas as early as possible.
Following is a discussion of some of the most common hand
fractures and frequently encountered complications.
e most frequently fractured bone in the body is the distal
phalanges of the digits.
107
People of all ages sustain ngertip
crush injuries during work and play activities. Fractures of the
most distal portion of these bones are called tuft fractures, are
often comminuted, and will usually require only a short period
of immobilization for comfort during the early stages of healing.
Healing may occur with a brous union, as opposed to ossication, yet be functionally stable and ultimately pain free. Two
common issues that may accompany these fractures early on include a subungual hematoma and hypersensitivity of the distal
aspect of the digit. Treatment for the former problem is relief of
pressure by allowing uid drainage of the trapped hematoma
through a hole drilled or burned through the nail.
and Rohde
108
note that although this will provide pain relief, it
14
Carpenter
turns a closed fracture into an open one and a short course of
antibiotics should be considered. Hypersensitivity of the distal
digit may be present for an extended period; therefore, a patient
may benet from a home program of desensitization activities.
A period of early protection with a plastic or aluminum
orthosis holding the DIP joint in extension for 2 to 3 weeks is
usually sucient to initiate the healing process and protect the
injured tissues. As the tenderness resolves, the protective orthosis may be removed to initiate gentle active motion of the DIP
joint. e MP and PIP joints motion should not be restricted at any time with this distal injury. Longitudinal fractures
or fractures of the base of the distal phalanx (particularly with
joint subluxation) may require reduction and percutaneous pin
xation.
109
e base of the distal phalanx is a common location for
avulsion injuries. On the dorsal aspect, if the terminal tendon
of the extensor mechanism is disrupted, the individual will develop a mallet nger deformity. In a mallet nger, the DIP joint
is in a exed resting posture and there is loss of active DIP joint
extension. e mallet nger injury may be a disruption of soft
tissue only, or a piece of bone may displace with the tendon.
Both the soft tissue disruption and a small bony avulsion are
frequently treated with a full-time orthosis for a minimum of 6
to 8 weeks with the DIP joint in full extension. Patients who do
not maintain the full-time orthosis positioning (24/7) during
this period often develop an extensor lag of the DIP joint. Patient education explaining how to change the orthosis and perform a skin check while maintaining the DIP joint in extension
107
is critical for best outcomes.
Most patients can perform this
edge while removing and replacing the orthosis. If there is a
large bony fragment disrupting the articular surface (>30%) of
the DIP joint or if a concurrent DIP joint dislocation cannot be
reduced, the bone fragment, or the distal phalanx, may require
110
surgical reduction and xation.
Clinical Pearl
A mallet nger injury that is accompanied by a hyperextension posture of the PIP joint may require an orthosis that
stabilizes the DIP in extension and blocks the PIP joint
from full extension.
On the volar surface of the distal phalanx, an avulsion of
the insertion of the FDP tendon can occur. is is a jersey nger
injury. Similar to the terminal tendon injury described above,
this injury can be a tear of soft tissue only or a piece of the
distal phalanx may have avulsed from the insertion site. A FDP
avulsion may occur on any nger, but most commonly occurs
111
on the ring nger.
e patient will present with the inability
to actively ex the DIP joint. Because the PIP joint often has
near full exion with the intact FDS, the evaluation must be
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39
completed carefully to not miss the decit at the DIP joint.
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e mechanism of injury is active DIP exion (eg, momentarily
grasping the jersey of an opposing player in football) followed
by a large force pulling the nger into extension (unable to keep
hold of the jersey as opposing player runs away). If this injury is soft tissue only, either a tendon-to-bone suture repair or
tendon-to-tendon repair is required. e rehabilitation following these repairs are discussed in the section on primary exor
tendon injuries and rehabilitation. On relatively rare occasions
however, a large piece of bone from the distal phalanx avulses
with the tendon. A large bony fragment can be pinned in place
and this injury is then treated as a fracture, requiring immobilization for 4 weeks in an intrinsic plus cast or orthosis. At the
time of a bony avulsion, the fragment may get stuck on the
pulley system of the nger exor tendons preventing the tendon
from retracting as far as it might otherwise. is makes it easier to return the tendon to its proper length, even in a slightly
delayed repair. In a soft tissue jersey nger injury, the active
exion forces on the muscle/tendon unit at the time of injury
may cause the tendon to retract proximally, sometimes as far as
the distal palm. is causes concern with a timely repair (within
111
1 week) due to the loss of nutrition to the tendon.
A plain
lateral view radiograph of the aected digit will often reveal the
bone avulsion versus the soft tissue tear.
Phalangeal fractures and metacarpal fractures are com-
mon, accounting for 23% and 18%, respectively, of below-
112
elbow fractures in the general population.
Fractures of these
miniature long bones of the hand have some commonalities in
that all must be assessed for angulation, rotation, or shortening that could aect functional movement. ere are however
some patterns that occur with frequency in each of the areas.
Recognizing these patterns allow the therapist to be particularly cognizant of known complications. e long insertion sites
of the FDS tendons on the middle phalanx may help to stabilize a mid-shaft fracture of this bone. A stable fracture may be
buddy-taped to a neighboring digit and treated with progressive
early motion. If an orthosis is needed, a nger-based orthosis
is designed to maintain the IP joints in full extension yet allow
freedom of the MP joints. e straps of the orthosis may be
removed so careful motion of both IP joints can be completed.
is same plan can be completed if percutaneous pinning was
needed to reduce an unstable fracture or to correct rotation and
110
alignment. However, as Shuler et al
pointed out, percutaneous pinning is not rigid xation. Careful monitoring of the loss
of alignment during early motion is important. Manually supporting the middle phalanx during active DIP joint exion and
extension ROM exercises can assist in maximizing tendon glide
and in fracture stabilization. Encouraging exion tendon glide
before scar adhesions develop is an important consideration
in rehabilitation following both middle and proximal phalanx
fractures. e type of xation, stability of the fracture, and tissue healing constraints must be carefully considered.
113
A hyperextension injury to the PIP joint may result in an
avulsion injury to the brocartilaginous volar plate on the volar
surface of a digit. Recall the volar (palmar) plate’s distal insertion is found at the base of the middle phalanx (Figure 6B). A
force across the PIP joint great enough to either cause a dorsal
dislocation or hyperextension deformity can avulse this structure. A lateral view radiograph of the involved digit may show a
bony avulsion, or the injury may be a soft tissue disruption only.
e majority of these injuries, even those with a small avulsion
fracture, can be treated nonoperatively. A nger-based blocking
orthosis is applied to the dorsum of the digit, blocking the PIP
joint in 25-30° of exion. Both the DIP and MP joints are free.
After 1 week of full-time orthosis use, a mobility program may
be initiated with a slow but progressive recovery of active and
passive PIP joint exion and active extension to the level of the
orthosis. Over the next 4 weeks, the therapist decreases the extension block 5° per week. By the time the orthosis is removed
at 4 to 5 weeks, the patient will have near normal exion and
extension. is protocol allows recovery of motion at the PIP
joint yet sucient healing of the volar plate for the recovery of
joint stability.
Proximal phalanx shaft fractures tend to angulate in a volar direction (volar apex) in part due to tension from the intrinsic muscles.
113
With the extrinsic nger exors intimately
associated with the bone, a primary rehabilitation concern is
the development of scar adhesions limiting exor tendon excursion. Angled, rotated, and displaced fractures often require
open reduction with internal xation (ORIF) for proper reduction. e ORIF can enhance outcomes as this may allow
early tendon glide exercises. Decreased exion tendon glide
(and therefore decreased active IP joints ROM) and PIP joint
contractures are 2 common consequences of displaced proximal
phalanx fractures.
114
Fractures of the middle and proximal phalanges as well as
metacarpal fractures should be carefully evaluated for rotational
deformities. Proper alignment should be assessed with the ngers placed in an intrinsic plus attitude and the position of the
distal ngertips observed. e patient’s hand should be turned
so you are observing the ngertips straight on. e gentle scalloped ends of the ngers should be in the same plane. A second
position used to assess normal versus abnormal alignment is the
FDS-only st posture. is places the MP and PIP joints in exion (no DIP joint exion). Now the ngers should gently point
to the scaphoid tubercle. Any scissoring or crossing over of the
digits may mean a rotational deformity. A therapist should be
diligent with this type of assessment when performing early motion activities, as a change in proper alignment with fractures
treated either nonoperatively or with surgical xation may indicate a loss of reduction. Figure 21 demonstrates a patient with
a metacarpal fracture with rotational malalignment and a resultant scissoring of the index nger. Recall the index metacarpal is
one of the stable rays, least tolerant of malrotation. Because this
patient’s fracture had already healed, a rotational osteotomy for
restoration of proper positioning was required.
40
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Figure 21.
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Metacarpal Fracture with Rotational
Malalignment
Clinical Pearl
Stiness of the small joints of the hand can readily develop
particularly if immobilization is held greater than 3 to 4
weeks. During the required immobilization, consider implementing edema control measures, assess for proper positioning, and initiate motion of uninvolved joints as soon
as possible.
e most common fracture of the metacarpals is the Boxer
fracture.
115
is metacarpal neck fracture occurs on the small
nger. e mechanism of injury is often from a punch with
a clinched st into a solid object with the axial load placed
through the ulnar side of the hand.
116
e result is exion of the
distal fragment (apex-dorsal at the metacarpal neck). A exed
position of the distal fragment of as much as 70° may be acceptable. Recall that the small nger is a mobile ray. e mobility
of the CMC joint of the small nger allows for malalignment
without compromising function. For a similar fracture, the stable rays would only tolerate a much lower exion deformity.
116
Treatment for a Boxer fracture usually includes an attempt at
closed reduction followed by cast or orthosis xation. An intrinsic plus posture with the IP joints free for movement allows
tendon glide exercises. Meals and Meals
14
reported that surgery
is reserved for patients who do not maintain an adequate reduction of angular and rotational deformity or who have damage to
an adjacent metacarpal. Strub et al
117
performed a prospective
in their cohort nonoperatively and others with reduction and
intramedullary pinning. ey reported greater subjective satisfaction with the appearance of the hand in the surgery group yet
both groups demonstrated similar functional outcomes.
Metacarpal shaft fractures typically displace with an
apex-dorsal angulation due to the pull of the intrinsic muscles.
Considerations again include assessment for rotation or angulation. Rotation is poorly tolerated and must be addressed if it
is present. Fractures of the index and small metacarpals, being
on the radial and ulnar borders of the hand are inherently less
stable than fractures of the long or ring metacarpals. e long
and ring metacarpals have some natural stability from the intrinsic muscles as well as from the neighboring metacarpals and
the transverse metacarpal ligaments. Nonreducible fractures
and fractures of multiple metacarpals are usually candidates for
surgical reduction and xation.
112
Metacarpal fractures can aect extrinsic extensor tendon
excursion. e injury may cause injury to the intrinsic muscles
as well. Isolating the action of the ED at the MP joint can improve tendon excursion and improve an existing extensor lag.
Strength and dexterity usually return with few problems in uncomplicated metacarpal fractures.
112
ough similar fractures of the distal and proximal phalanges of the thumb do occur, 2 named fractures of the thumb
metacarpal are worth separate consideration. Both fractures occur at the base of the thumb metacarpal and both require reduction and pinning or internal xation due to their displacement
patterns or intraarticular nature at the mobile CMC joint.
A Bennett fracture is a fracture-dislocation. A triangular
portion of bone is avulsed from the ulnar side of the metacarpal
base. e injury occurs from excessive abduction forces combined with an axial load at the rst CMC joint. e avulsed
fragment is the attachment site of the palmar oblique ligament,
a stabilizer of the metacarpal to the trapezium. Without this stability, the remaining metacarpal subluxes or dislocates in a proximal and dorsal direction by the deforming force of the APL
muscle. Proper reduction, pinning or other internal xation,
and lengthy immobilization (8 weeks full-time and another 3 or
more weeks part-time) is typically required for this fracture. Initial rehabilitation focuses on recovery of CMC joint palmar and
radial abduction and opposition motions, followed by strengthening of thenar intrinsic muscles. Heavy gripping and pinching
activities are typically avoided for at least 3 months.
A Rolando fracture also occurs at the base of the thumb
metacarpal. is fracture has 2 or more fragments on the articular surface. is comminuted fracture may be more dicult
to reduce with xation ranging from percutaneous pinning to
plate and screw xation.
109
After a period of immobilization,
focus will be the recovery of functional motion of the thumb.
With the involvement of the CMC joint in these thumb intraarticular fractures, a consequence can be loss of palmar abduction limiting functional grasp. Gallagher et al
118
recommend
a hand-based orthosis for serial web-space stretching if this
complication occurs.
Finger and thumb sprains
As is the case with fractures, soft tissue injuries about the
joints of the hand may lead to negative outcomes. A short peri-
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41
od of immobilization may result in the loss of motion in multi-
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ple joints and even a small amount of joint eusion can restrict
motion. e delicate balance between the exors and extensors
across the IP and MP joints can be disrupted resulting in an
abnormal resting posture and the potential loss of function. Rehabilitation needs to balance immobilization as needed, edema
control, and early tendon glide through a safe ROM program.
Following are examples of some of the commonly treated soft
tissue injuries of the nger and thumb joints.
A common soft tissue injury of the MP joint of the thumb
is a UCL disruption. Hyperextension with radial deviation at
the thumb MP joint can sprain or rupture the UCL, most often
from its distal attachment on the proximal phalanx. An acute
injury is known as a skier’s thumb due to the high incidence of
this injury in downhill skiers (the pole forcing a hyperabducted or hyperextended with radial abduction position of the MP
joint during a fall). e term Gamekeeper’s thumb is used at
times interchangeably, though this is referring to a chronic condition from a repetitive activity which over time creates UCL
68
laxity.
e key to treatment of UCL injuries is proper diag-
nosis that dierentiates a complete rupture from a grade I or II
68
sprain.
Tosti and Jacoby68 outlined the following treatment for
grade I and II injuries. For the initial 2 to 4 weeks, the patient
wears a hand-based thumb-spica orthosis or cast with the IP
joint free. Following immobilization, the therapist can begin
key pinch and gentle thumb strengthening for the next 3 to 4
weeks. e patient avoids tip pinch and grasping until 8 weeks
after treatment and should not participate in aggressive therapy
programs. Stability is always given precedence over motion in
this early period for this injury.
68
Figure 16A demonstrates an examination of a grade III
UCL sprain under anesthesia. In this case, the patient had already been diagnosed of a suspected Stener lesion and was in the
operating room for surgical xation. Typically, in a grade III disruption there will be 10-15° greater laxity into radial deviation
compared to the contralateral side, combined with the absence
of an endpoint.
68,116
e test is described in the Examination
section of this monograph. Complete UCL ruptures (grade III)
can be treated nonoperatively if a Stener lesion is ruled out.
e Stener lesion describes a UCL that has retracted proximally
and dorsally to where it may now be laying over the adductor
aponeurosis. Such a retracted ligament cannot successfully heal
to the insertion onto the proximal phalanx. Figure 16B shows
the “balled up” ligament present in this scenario. A radiograph
may demonstrate a bony avulsion allowing the examiner to determine if the ligament has retracted. If there is no evidence of
bony avulsion, and a Stener lesion is suspected, surgical intervention involving exploration and ligament repair (open repair
or arthroscopy) is typically recommended. erapy typically begins 4 to 6 weeks post-surgery with exion and extension ROM
exercises followed by progressive resistance exercises with MP
joint stability as the primary concern as mobility slowly recovers. e patient usually returns to full activities at 3 months
following surgery.
e PIP joint is the most commonly injured joint in the
119
hand.
is hinge joint is vulnerable to excessive hyperextension, axial loading, and rotational stress because of its long lever arms. Patients may not have sought immediate attention,
frequently saying “it is just a nger, and I thought it would get
better on its own.” Proper compliance with short-term protection is important for regaining pain-free stable joints following
traumatic injuries. Grade I injuries produce excessive tensile
stress in a collateral ligament but do not disrupt the continuity
of the ligament. ese injuries are stable through full AROM
of the joint, but the ligament is tender to palpation and pain
is reproduced with stress testing. A therapist can treat a grade I
PIP joint collateral ligament injury with 1 to 2 weeks of buddy
68
taping.
Buddy taping will allow the desired early motions in
exion and extension of the IP joints yet prevent medial and
lateral stresses upon the joint.
Clinical Pearl
Buddy taping can exacerbate a PIP joint eusion with
straps placed distal and proximal to the joint. Consider
the use of 1-inch compression wrap the length of the nger rst, then the placement of the buddy straps or tape.
Re-wrap the compression tape at least every 24 hours and
perform a skin check.
Grade II collateral ligament injuries involve partial dis-
ruption of the ligament. ough pain and mild laxity may be
68
observed with stress testing, a rm end point is felt.
ese
injuries require an immobilization period (2-4 weeks) in a gut-
118
ter orthosis with the involved IP joint in full extension.
e
patient can perform early AROM exercises in exion/extension
if medial and lateral forces are avoided. Buddy taping continues for an additional 2 weeks following removal of the orthosis.
e therapist addresses the fusiform swelling characteristic of a
PIP joint injury early with retrograde massage and compression
wraps. e therapist should not neglect the DIP joint, which
118
often becomes sti during PIP joint rehabilitation.
Grade III collateral ligament injuries result in complete ligament rupture as well as an injury to the volar plate or dorsal
capsule. A volar or dorsal dislocation may also have occurred
at the time of injury. ese patients must be immobilized, preventing motion in the arc of movement where instability is present, which is usually end range PIP joint extension (0-25°).
118
Treatment of the volar plate injury was described in the section
on avulsion fractures. For complete collateral ligament injuries,
the therapist may choose the same treatment as an isolated volar
plate injury, but 1 to 2 weeks of buddy taping may be added to the dorsal nger orthosis use to decrease the medial and
lateral stresses on the joint. e patient wears the orthosis for
a shorter time, 3 weeks instead of 5, if there is no volar plate
avulsion. When use of the nger orthosis is discontinued, the
42
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patient uses buddy taping as needed during daily activities and
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particularly for more vigorous activities such as return-to-sport.
For all collateral ligament sprains and PIP joint injuries, edema
management with compression, retrograde massage, and active
pumping exercises (when indicated) are an integral part of re-
ROM exercises, including intrinsic muscle stretching, with
gradual return to progressive resisted exercises.
Proximal IP joint injuries that cannot be stabilized using
nonsurgical treatment or those that are unstable in angles > 25°
of exion require surgical repair.
110
Be aware that a PIP dislocation may have self-reduced. An intraarticular fracture may
occur at the time of injury, or at the time of reduction. Recommendation is for a radiograph of the involved digit to be performed following joint reduction to conrm a successful reduction and rule out an associated intraarticular fracture. Recovery
of joint motion following a PIP joint fracture-dislocation can
be signicantly limited even with acute surgical interventions.
A missed intraarticular PIP joint fracture-dislocation (no nger
radiograph obtained), or delayed repair (wait to the end of a
sport season) may have few treatment options and result in limited motion recovery.
Carpal fractures
A FOOSH can result in dierent injury patterns of the distal upper extremity. Depending on the energy transmitted, the
integrity of the bone and supporting soft tissues, the angle of
the wrist and forearm at impact, a plethora of injuries can result.
e most common upper extremity FOOSH injuries involve
the wrist bones including the distal radius and ulna and the
scaphoid. Let’s consider the pathologies of the carpal bones and
surrounding soft tissue rst, and then look at the very common
pathology, fracture of the distal radius.
e scaphoid is the most frequently fractured of the carpal
bones, accounting for up to 68% of all carpal fractures.
53
As
stated in the anatomy section, the scaphoid spans the midcarpal joint, it is particularly vulnerable to excessive tensile force
during a FOOSH injury when the hand lands in wrist hyperextension and radial deviation. Approximately 70-80% of
scaphoid fractures occur at the waist of the bone, and 10-20%
occur at the proximal pole.
120
is injury occurs most often in
young active persons resulting from relatively high energy traumas. A scaphoid fracture may at rst be mistaken for a wrist
sprain, and therefore, proper evaluation and treatment may be
delayed. Such a delay in the identication and treatment of this
injury can increase the chance of the development of a scaphoid
nonunion and avascular necrosis of the proximal fragment. e
long-term eects of a scaphoid nonunion can be the development of a scapho-nonunion advanced collapse (SNAC) wrist
deformity. A SNAC wrist may ultimately result in complete
carpal breakdown with loss of normal alignment at both the
radiocarpal and midcarpal joints and between the carpals within the proximal row. Treatment options are varied but typically
require some form of salvage procedure to control the degenerative changes at the wrist such as a proximal row carpectomy or
a partial wrist fusion.
121
e initial symptom of a scaphoid fracture is dull, deep,
radial-sided wrist pain. Pain may be reproduced on direct palpation of the scaphoid in the anatomical snubox, at the SL
joint line, or on the scaphoid tubercle. Palpation in the base of
the snubox will place the examiner’s thumb over the waist of
the scaphoid. If initial radiographs are negative, yet the history
of injury and signs and symptoms indicate a potential fracture,
immobilization in a thumb-spica orthosis or cast is recommended for 2 weeks with a repeat lm then taken. Advanced
imaging studies may be ordered if a denite answer is required
sooner, such as for return to professional sports activities. Magnetic resonance imaging may be recommended for patients with
persistent symptoms of a fracture despite negative plain lms results, when a scaphoid fracture needs to be ruled out quickly for
a potential return to competition such as in professional sports,
or when a conrmed scaphoid fracture must be further assessed
for surgical consideration.
118
Nondisplaced distal pole fractures usually heal in 8 to 10
weeks with a forearm-based thumb spica cast. Waist (mid-pole)
and nondisplaced fractures may require up to 3 months of cast
immobilization. Displaced, unstable, and proximal fractures
require surgical xation. Post-surgery, the surgeon immobilizes
the thumb and wrist in a forearm-based thumb spica cast until
there is radiographic union, usually within 6 to 12 weeks. e
therapist then fabricates a forearm-based thumb spica orthosis,
which the patient wears an additional 4 weeks. Following the
long immobilization period, soft tissue, joint capsule, scar, and
carpal mobilizations are essential. Upon conrmation of bone
healing, strengthening is gradually introduced with attention to
endurance and dexterity activities.
Other carpal fractures in isolation do occur but are signicantly rarer than scaphoid fractures. Catalano et al
7
list carpal
fracture frequency from most to least as follows: scaphoid 68%,
triquetrum 18%, trapezium 4%, lunate 4%, capitate 2%, hamate 2%, pisiform 1%, and trapezoid 0.5%.
e most common cause of fractures of the triquetrum is
a FOOSH with the hand landing in hyperextension and ulnar
deviation that drives the ulnar head into the triquetrum.
122
Two
fracture patterns are typically seen: (1) a small piece of cortical
bone is displaced from the dorsal surface; and (2) a transverse
fracture through the body of the bone. e avulsion fracture
can typically be treated in a wrist cast (3-4 weeks) followed by
a removable cock-up orthosis and progressive recovery of motion. ough this avulsion injury may appear to be relatively
benign, there is some concern of carpal instability if this injury
is ignored due to its location close to the insertion of the dorsal
intercarpal ligament and dorsal radiocarpal ligament.
Almost all cases of carpal fractures that demonstrate fracture displacement, ligament instability, and/or combined injuries patterns will require more aggressive reductions, xations,
and rehabilitation.
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43
ough not seen in high frequency, a fracture of the hook
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of the hamate deserves attention. is fracture most often occurs
as a result of a compressive force transmitted through the base
of the palm, or shear forces during active torque of the wrist, as
seen with the use of a tennis racquet, baseball bat, or golf club.
A patient with an undiagnosed hook fracture may complain of
pain with gripping activities and when weight bearing through
the palm, as well as tenderness with direct palpation over the
area of the hook. Conventional radiographs do not properly reveal the fracture. A carpal tunnel view (the hand placed in full
extension, and the beam angled through the carpal tunnel) is
8
best to reveal a fracture here.
Immobilization in a cast for 6 to
8 weeks is the recommended treatment for nondisplaced fractures; displaced fractures require surgery.
Clinical Pearl
Distal ulnar neuropathy may be a consequence of a missed
hook of the hamate fracture. Recall the hook forms the
radial border of Guyon’s canal. A displaced fragment may
compromise the ulnar nerve and artery as they move into
the enclosed space. Examination for a suspected hook fracture should include a thorough neurovascular assessment
of the ulnar nerve and artery. Consider this also in reverse,
if a distal ulnar neuropathy is obvious on your examination, consider the hook of the hamate fracture as a possible
cause.
Wrist sprains
Normal wrist function requires precise interaction between
joint surfaces, tendons, ligaments, and other soft tissues. Disruptions of 1 or more of these structures can aect the harmony
of the wrist working as a unit. Authors describe the carpus as
a ring system in which the bones within each carpal row are
123
tethered together by interosseous ligaments.
e ring is only
complete however by the inclusion of the midcarpal ligaments.
ese ligaments are the connection between the proximal and
distal carpal rows. In this system, as long as the ligaments are
intact, the bones will move together as a unit. ere is some
known independent motion between carpal bones but the clinical relevance of this information and diagnosis and treatment
selection is still unclear. e extrinsic ligaments proximally from
the radius and ulna and distally from the metacarpals further
support the carpals. Disruption of even portions of this complex wrist unit can lead to some well-described instability patterns of the wrist.
A high energy FOOSH, is the primary mechanism of injury of soft tissue disruption within the carpus. e alignment of
the carpals of the proximal row is an important key to the level
124
of ligament disruption. Mayeld et al
report a progression of
force transmission through the wrist that can cause ligament
tears about the lunate. e soft tissue disruption can begin with
a relatively mild partial sprain of an interosseous ligament within the proximal row but as forces progress, ligament disruption
may result in complete disruption of the soft tissues around the
lunate, leading to lunate dislocation. e 4 basic stages of force
7
transmission and resultant ligament injury patterns are:
(1)
Minor sprain to the palmar aspect of the SL ligament without total disruption (if the wrist is radially deviated and
hyperextended, a scaphoid fracture also occurs).
Continuing force, causing dissociation of the SL ligament
(2)
(characterized by disruption of rst, the palmar, and second, the dorsal aspect of the SL ligament). A lateral view
radiograph of the wrist taken at this point would show dorsal angulation of the distal surface of the lunate in relation
to the scaphoid.
(3)
Continuing hyperextension causes additional force transmission through the wrist; the ulnar limb of the arcuate
ligament may pull the triquetrum dorsally, causing failure
of the LT ligaments.
Lastly, the RSC ligament forces the capitate to collapse into
(4)
the radiocarpal space and pushes the lunate in a palmar direction until it dislocates into the carpal tunnel in a rotary
manner. e result is a complete lunate dislocation.
Following a dislocation, the lunate may spontaneously reduce, leaving little clinical evidence of dislocation other than
recurring pain and eventual instability. If the lunate does not
reduce, there will be visible and/or palpable deformities in the
wrist. If the lunate is displaced volarly, there is potential for median nerve compression. Fractures often accompany a lunate
dislocation, further complicating recovery and rehabilitation.
High-energy trauma may produce a perilunate fracture-dislocation, with a trans-scaphoid fracture being the most common
injury combination.
125
Injuries of the wrist of this nature, unless they are diagnosed as a fracture or dislocation, may be missed in the acute
stage. e initial pain may resolve, but over time (can be
months or years), symptoms will recur. When asked, patients
may report a history of a wrist sprain that resolved over time.
Symptoms therefore may occur at the time of the acute injury
or signicantly later.
ere are both static and dynamic instability patterns of
the wrist. In a dynamic pattern, there may not be evidence of
abnormal carpal movement patterns unless the carpus is stressed
by placing the wrist into dierent positions for a radiograph.
A wrist motion series (radiographs taken in exion/extension
and radial/ulnar deviation) may be necessary for diagnosis. For
diagnosis of a static instability pattern, at least some of the radiographic signs listed later in this monograph should appear
on routine PA or lateral wrist radiographs. Signs include abnormal gaps between individual carpal bones, alteration in the
shape or appearance of individual bones, and the loss of smooth
appearing arcs across the midcarpal and radiocarpal rows. Fig-
ure 22 shows a PA wrist radiograph demonstrating the most
44
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