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Rehabilitation in Congenital
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Hand and Forearm Defects:
Rehabilitation of the Child’s
Hand—General Aspects
ElenaM.Mancon, LuigiBartolomeo,
ElisaCeccarelli, SaraCesaroni, ClaudiaCorsi,
GretaCulicchia, AmbraGelatti, RobertaGenova,
AntonellaGuerriero, SaraLonghi,
ClaudiaMaiolino, CarmenMeloni, SilviaMinoia,
MartaNobilia, RossellaPagliaro, StefaniaPaparo,
ValeriaL.Petrillo, MichelaRamella,
FedericaSuriano, PatriziaRossi, FrancescaTolosa,
andSimonaVecchi
34
Abstract
Patients affected by radial club hand present
different aspects all involving the general use
of the entire upper limb: shorter forearm,
radial deviation, low to severe dysfunction of
the thumb or in the most severe stages, its
absence and reduced AROM (active range of
motion) of long ngers.
The major problem during the growth of
those patients is the frequent recurrence of
relapses that may occur despite the kind of
surgery performed: this can be due to different
causes linked both to intrinsic factors such as
E. M. Mancon · L. Bartolomeo · E. Ceccarelli
S. Cesaroni · C. Corsi · G. Culicchia · A. Gelatti
R. Genova · A. Guerriero · S. Longhi · C. Maiolino
C. Meloni · S. Minoia (*) · M. Nobilia · R. Pagliaro
S. Paparo · V. L. Petrillo · M. Ramella · F. Suriano
P. Rossi · F. Tolosa · S. Vecchi
Department of Hand Surgery and Rehabilitation,
San Giuseppe Hospital IRCCS MultiMedica,
Milan University, Milan, Italy
Milan, Italy
e-mail: elenamarta.mancon@multimedica.it
the impossibility of releasing radial soft tissues completely or extrinsic elements such as
the poor use of a proper splint and the frequent
stimulus to the radial deviation due to functional gestures like bringing the hand to the
mouth. Unfortunately, the clinical situation
can be considered stabilized only with the end
of physiological bone growth.
The rehabilitation programme begins taking charge of the patient after the rst visit
with the surgeon. It is divided in two different
approaches:
• Conservative treatment: it starts immedi-
ately after the visit and lasts in the pre-
operative time.
• Post-surgery treatment: it starts after the
surgery.
In both, the treatment is endorsed by the
surgical team, the therapist and the patient’s
family, who becomes both a receiver and an
active participant in the rehabilitation
process.
© Springer Nature Switzerland AG 2023
G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_34
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Keywords
Radial club hand · Hand malformations
Children’s hands · Rehabilitation in paediatric hand malformations · Thumb dysfunction
Trigger nger · Thumb · Rehabilitation
Conservative · Splint · Congenital malformation · Syndactyly · Finger · Hand malformation · Congenital hand rehabilitation
Polydactyly · Radial polydactyly · Ulnar
polydactyly · Central polydactyly · Amniotic
band syndrome · Hand · Blood circulation
Constriction · Thumb hypoplasia
Opponensplasty · Pollicization · Pinch · Club
hand · Splinting · Manipulation · Children
Psychomotor · Therapy · Body · Mind
Congenital hand malformation
Children are our present and future, so they need
the most specialized and prepared equipe as little
patients.
When they get to the hospital to be visited,
they normally do not understand why their parents took them to that strange and new place,
especially if they are very young as it normally is.
That is why the equipe as big team needs to
make children feel at home, through different
tools.
34.1 Setting
In the pediatric eld more than every other medical elds, the setting is very important to catch
the attention of the little patient and the parents
too. They need to have around them a familiar
atmosphere when possible with bright colors, and
different rooms for the rehabilitation of different
ages of children.
Normally in pediatric rehabilitation departments, therapists need more than one single room
to work in.
They will need a room with a kettle/heater and
a table to make splints. To make splints you need
different types of thermoplastic materials, velcros, scissors, a riveter, a stripper (?), padding,
etc.
Then therapists will need a sanitary cot for
children younger than 3 months of age as putting
them on the ground and also on soft carpets can
be uncomfortable for parents and the therapists
themselves.
Another room can be structured with soft carpets on the ground and pillows; this room can be
suitable for children from 4/5 months until about
18/24 months. In this way children can be protected from falls and can be comfortable in sitting, lying, or side position.
At last but not least, it is important to have a
small table with chairs for 20/36 months old
children.
Children normally are a little worried at rst
during physiotherapy but they love to play and
during rehabilitation there is a lot of fun too.
Talking about setting, we have to underline the
importance of closets. Children normally like to
change toys and games more often than they
should so it is appropriate to have closets to store
toys; in this way the child can choose with the
therapist one game at the time.
Children older than 4 years of age need a
proper table and proper chairs too.
We have to admit that these are the most
appropriate spaces that we can suggest, but it is
not always possible to have all these rooms, if it
is not the therapists have to do their very best
with the space that they have, putting the safety
of the child at the rst place (Images
34.1–34.4).
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Images 34.1–34.4 The setting
34.2 Rehabilitative Program
When a child and his family come to our attention it is for sure after a surgical visit. The surgeon may suggest rehabilitation before or after a
surgical operation.
Either if is before surgery or after it is very
important to schedule with the family and in
agreement with the doctor the length and the frequency of the rehabilitation that should change
from a little patient to the other to follow their
necessities.
In a conservative treatment normally, especially if the child is very young we do rehabilitation sessions ones a week, or maximum twice a
week at the beginning. This allows the parents to
understand what they are supposed to do with
their children as home exercise, and the therapist
can control the growth and the improvements of
the little patient. Splint checks are required during rehabilitation too, when the child grows up
the splint needs to be replaced.
After surgery the patient can keep the immobilization or the dressing for 3/4 weeks and then
they normally suggest daily physiotherapy, and
in some cases twice a day. There are some cases
in which rehabilitation is immediate.
Daily physiotherapy is useful at the beginning
because the child has to get used to the “new situation” of the hand; proper stimulation and manipulation are essential. The parents are supposed to
exercise very often at home too, so they participate in the session to learn how to help their children. After a few weeks the sessions can be
normally reduced, three times a week and then
two times, then one and so on.
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The rehabilitation program is defined by
the therapist in collaboration with the surgeon
and parents and has to be followed precisely
by all the members of the equipe; obviously it
can be changed later on if required by the
situation.
34.3 Assessment
In pediatric rehabilitation, assessment of the
child is very important to set up the rehabilitation
program correctly.
Basically the assessment should be based on a
double approach. First the child as a young infant
needs to be valued in his psychomotor complexity. It is very important for children to respect
psychomotor stages, as any other child; the therapist’s task is to check them during their growth.
Second the therapist should evaluate the use of
the upper limbs, their functionality, and the
different grips and pinches the child is capable of
doing. Furthermore, it is important to analyze if
the limb difference affects the activity of daily
living or the quality of life of the child and
family.
To understand if the child is respecting the
physiological psychomotor steps, it is necessary
that all the health workers who deal with little
patients know them well. That is why we decided
to produce some tables that could summarize the
most important ones, divided in ages.
34.3.2 3–6 Months
Motor skills Antigrait control of the
head-trunk
Prone position with upper
limb support
Beginning of rolling
Manual skills Eye-object-hand-mouth
Catch
Interpersonal skills Beginning of separation
from adults
Follows auditory and visual
stimuli
Communication and
language
Independence X
Babbling
34.3.3 6–9 Months
Motor skills Independent sitting position
(parachute)
Pivoting
Lie down position to sitting
position
Sitting position to all-fours
position
Creep and crawl
Manual skills Inferior pinch (abduction of
the thumb)
Extended wrist in the grips
Voluntary release
Interpersonal skills Permanence of the object
Search of people and objects
Communication and
language
Independence Play
Comprehension of verbal
language +
Feeding
34.3.1 0–3 Months
Motor skills Median line
Manual skills Eye-hand-mouth
Interpersonal skills Attachment to parents
Communication and
language
Independence X
Antigrait control of the
head
Upper limb +
Lower limb −
Tactile exploration
Consolability
Cry
Smile/pout
34.3.4 9–12/18 Months
Motor skills Standing with support
Side steps
Be able to fall
Standing alone
Autonomous walking
Manual skills Superior pinch
Point
Small objects
Interpersonal skills Permanence of the adult
Problem-solving
Imitation
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Communication and
language
Independence Feeding
Words
Simple verbal
commands
Sleep
34.3.5 18–24 Months
Motor skills Run
Jump
Overcomes obstacles
Manual skills Fine dexterity
Bimanuality
Interpersonal skills Symbolic games
Sense of themselves
Emotional variability
Communication and
language
Independence Meals
Proper vocabulary
Beginning of sphincteric
control
34.3.6 24–36 Months
Motor skills Stairs
Ride
Manual skills Fine dexterity+dominant
side, hand
Interpersonal skills Rules
Socialization
Communication and
language
Independence Eat with cutlery
These tables can be useful in daily practice to
understand quickly if a child is respecting his
psychomotor growth or not, and this can also
help the therapist to focus the rehabilitation program on that single patient.
A comprehensive evaluation may include
range of motion measurements, sensory testing,
strength and functional testing, self-care and
playing skills, and developmental assessments.
There are also validated scales to use, if necessary (about the children development), like the
“Grifths mental development scale” or the
“Bayley scales of infant and toddler develop-
Vocabulary+sentences
Sphincteric control
Personal care
ment,” in its third edition. The positive aspects of
using a validated scale is that the result can even
be diagnostic and used also in collaboration with
a neuropsychiatrist, particularly of syndromic
patients. On the negative side we have that it is
necessary to attend a long and expansive course
to be able to administer them, and specic tools
are needed too.
It is possible, however, to nd some easier
charts about children developmental screening
such as “Ages and Stages Questionnaires (ASQ-
3),” the “Ireton’s chart,” “Denver developmental
screening test (DDST),” “Battelle developmental
inventory (BDI-2),” and “Pediatric evaluation of
disability inventory (PEDI).”
It is globally recognized that it is important to
focus on the child’s abilities and not on its disabilities, as reported in the International
Classication of Functioning Disability and
Health (ICF-CY) and psychomotor development
milestones as described also by the World Health
Organization (WHO Motor Milestones).
New studies have been conducted about a
global assessment that can include grips, complex
use of the upper limb, and quality of life adaptable
also to child with limb differences like our little
patients. However this international and multicentric studies are not currently completed and it is
still not possible to use them in daily practice.
The Pediatric Outcome Data Collection
Instrument (PODCI) is a commonly used assessment tool to evaluate the outcome and function in
pediatric orthopedic population. There are also
other key performance indicators for evaluating
the health system in a global way, like the Patient
Reported Outcomes Measures (PROMs). They
can provide validated evidence of health from the
point of view of the little patient. Some studies
underlined that a child is able to self-report his
well-being and function only after he is between
5 and 8 years old. Unfortunately it is really difcult to nd a scale that can be perfect for our children. In fact hands can be very different one from
the other and it is barely impossible to make
comparisons. It is also very hard to have one single scale for children of different ages, because
obviously each age has specic skills.
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Most scales suitable for children and upper
limbs are made for neurologic patients, and this
is for sure a limit, like the “Abilhand Kids,”
“Bimanual Motor Function Classication
(BFMF),” “Gross Motor Functional Classication
System (GMFCS),” and “Mini-Manual Ability
Classication System (Mini-MACS).”
However is still possible to measure the range
of motion (with goniometers), and the strength of
the pinch and grasp, also through new electronic
devices (Exergames).
There are lots of scales that can assess the
quality of life of young infants like the “PedsQL.”
Without having the possibility to administer a
single scale per patient, the therapist’s observation, records, joints measurements, strength measurements, pictures, and videos are essential to
understand and recognize our little patient’s
improvements.
All these different assessment tools remind us
of the importance of the difference between what
children are able to do (function) and how they
feel about it (well-being).
34.4 Splinting
Splinting is for sure one of the most important
tools that we, as hand therapist, have for children
with hand malformations.
Indication of splinting can be given from the
surgeon after an operation in order to protect the
limb, can be chosen to protect the hand after a
period of immobilization, or can be chosen by the
therapist to obtain a determined position.
There are endless possibilities of splints for
children: different materials, thickness, elasticity,
sizes, but the major subdivision is between xed
splint and removable ones. With “xed splints”
we mean splints that cannot be removed, they can
be suggested after surgery or after fractures, normally in children splints need to be particularly
resistant and are a little bit wider that in adults to
allow children to play and go to school with the
immobilization without risks. Removable splints
can be worn or taken off, and this is allowed by
Velcro. The posology of the splint is decided by
the therapist and the surgeon.
There is no age limit for splinting; in our experience we did splints also on a 7-day-old child,
and the younger is the child the most the splint
need to be correctly padded. For extremely young
children sometimes the Velcro is too stiff, and
splints are xed to the limb with soft bandages.
Very stiff material is not needed for smaller
hands, also if the position of the hand, ngers, or
elbows has to be correct a semi-rigid material can
be enough (Images 34.5–34.7).
For children that are more than 6/7 months of
age some tougher material can be used.
Another very big subdivision between types
of splints is between static, dynamic, or static
progressive splints. A static splint keeps a position that the segment can reach, a dynamic splint
Images 34.5–34.7 Splints
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Image 34.8 Dynamic splint with elastic for elbow
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has a dynamic traction to beat a stiffness (caused
by joint stiffness or scar stiffness for example),
and a static progressive splint has a static traction
that can be regulated by the parent or the therapist. For dynamic splints the therapist needs also
leather (more comfortable than Velcro on the
skin), shing wire, and different kind of elastics
(Image 34.8).
It is very important to choose the correct type
of material and splint for a single little patient: if
a xed splint is made with a soft material it cannot be protective enough, if a stiff thermoplastic
material is chosen for a very young patient it can
be dangerous for the skin, if a dynamic splint is
not correctly padded it can be harmful for the
child. So choosing the correct splint and correct
material is very important, but respecting the anatomical point (punti di repere) is essential, for
example a splint that blocks the wrist and one ray
lets the long ngers free to move have to be under
the line of the heads of the metacarpal heads.
Thermoplastic material is washable with cold
water, and this is very important for children; an
extra portion of padding is given to the parents so
they can change it if necessary.
34.5 Scar Management
34.5.1 Introduction
Any surgery or skin lesion produces a scar. It
may be normal, atrophic, hypertrophic, or
keloid. The hypertrophic and keloid scars are
Image 34.9 Example of pediatric scar
formed as a result of the process of abnormal
wound healing, causing aesthetic and functional
decits, discomfort, and disturbances in the normal growth of children. In hand rehabilitation
departments, most of the treated scars are surgical, but often there are also traumatic scars due
to cutting injuries, crushing, or burns. However,
any wound can have complications due to intrinsic (patient) or extrinsic factors (type of intervention, technique, medications used, etc.)
(Image 34.9).
34.5.2 Evaluation
An appropriate classication of scars is a signicant element because the differences in their
clinical types determine the type of therapeutic
approach. The evaluation of a scar must examine three important aspects: physical characteristics, aesthetic aspect, and the patient’s
symptoms. For the physical characteristics, it is
fundamental to analyze the thickness, the relief
that is the height of the scar which is variable
according to the scar maturation, the exibility
that represent the extensibility, elasticity, and
stiffness of the scar. In fact, a scar lacking exibility can contribute to the loss of movement
and therefore represents an important evaluation
index. For the aesthetic aspect, it is important to
observe the color of the scar, which is due to
both vascularization and pigmentation. The
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Images 34.10 and 34.11 Example of scars
E. M. Mancon et al.
degree of vascularization is connected to the
wound healing phase; in fact, the active scars
have a greater blood supply and therefore will
appear reddened. Patient symptoms are also
essential: pain and itching are the most common. In the literature there are scales that allow
to evaluate and monitor the progress of the scar
during treatment. Among these are the
Vancouver Scar Scale, Hamilton Scale, and
Patient and Observer Scar Assessment Scale
(P.O.S.A.S). Unfortunately, children’s scars are
hardly measurable due to growth. Therefore, an
objective evaluation is often used by observing
color through visual evaluation or photography,
analyzing movement of joint with regard to exibility, or using the measurement in centimeters
for thickness (Images 34.10 and 34.11).
34.5.3 Treatment
Scarring is a dynamic process with marked activity in the rst 18 months. Knowing the factors
that inuence this process, prevention of the formation of keloid or hypertrophic scars is more
effective than their subsequent treatment.
Therefore, the entire treatment of post-surgical
wounds is subject to a single objective, that is the
reduction of the risk of developing pathological
scarring, in order to guarantee the best possible
aesthetic and functional result. In our hand rehabilitation department, post-surgical scars of children with different congenital malformations are
often treated: syndactyly, symbrachydactyly,
camptodactyly, clinodactyly, hypoplasia and
thumb agenesis, arthrogryposis, polydactyly,
amniotic reins syndrome, trigger nger. After the
surgery, the scar treatment is started only when
the wound is completely healed, which usually
occurs around 21 days. The scar must be elastic,
non-hypertrophic, non-adherent, nonhypersensitive, and non-painful. It is necessary to
remove any necrotic material through good
cleansing or with warm baths. The massage is the
rst approach used. It improves skin hydration,
reduces itching and pain, and also helps the little
patient to accept the scar and his hand. The therapist explains to parents the importance of massage and the need to perform it independently at
home. Parents are instructed on the correct technique of massage, which must be done in a rotational sense, without rubbing but lifting the scar
from the deeper levels, using an emollient cream.
It must be performed at least 4 times a day for
about 10min. Parental constancy in massage and
scar treatment is essential for successful treatment. Furthermore, continuous monitoring by the
therapist is necessary, which allows to intervene
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in case of excessive inammatory reaction to the
treatment. If the scar appears hypertrophic, silicone sheets are applied to the scar overnight,
until it is improved. They improve scar hydration,
color, and reduce height and volume.
Alternatively, the elastomer (silicone polymer) is
made, the advantage of which is to be modeled
directly on the patient’s skin. Also, it could be
used as an evaluation tool. In fact, by modeling it
on the skin, the negative mold of the scar remains
so as to be able to evaluate its evolution over
time. If the scar is adherent to the underlying tissues, vacuum therapy is used. To allow home use,
the “succhiaveleno syringe” is recommended, a
syringe without a needle that produces negative
pressure by lifting the supercial tissues. The
application of k-tape can help to maintain rehabilitation control. It can be applied both with
50% voltage and without voltage. If the scars are
in the commissure of the hand (pathologies such
as syndactyly, Simbrachidattilia) a static “saddle”
splint is made to be worn during the night, to
allow a prolonged compression on the commissure scar. It also helps to keep scars stretched for
a long time. Another aspect to consider is the
hypersensitivity that affects the scar tissue, which
can represent a limit in the daily use of the hand.
In these cases, a desensitization program is carried out through sensory stimulation with different types of objects or tissues of increasing
discomfort, in order to bring the scar area back to
a normo-sensitivity. The rehabilitative treatment
described above is not always sufcient for denitive resolution. If the scars become retractable,
causing a functional decit, a surgical correction
will be performed.
34.6 Trigger Finger
Trigger nger of the thumb and long ngers in
children must be evaluated by a hand specialist.
After the diagnosis, a conservative or surgical
management is started, both including an appropriate rehabilitation protocol.
In some cases a conservative treatment can be
started even if surgical approach is the surgeon’s
choice, to reduce stiffness and pain before
surgery.
The collaboration between the hand therapist
and the surgeon is very important in order to
apply the correct rehabilitation protocol.
34.6.1 Conservative Treatment
Short-term aims:
– Improving PROM/AROM
– Reducing stiffness
– Reducing pain
– Tendon sliding
Long-term aims:
– Complete PROM/AROM with no pain and
stiffness
– Recovering complete use of the hand
The hand therapist has several tools and strategies: it is very important to involve parents and
caregivers in the rehabilitation protocol to obtain
better results.
34.6.2 Splinting
It is very important for the little patient to have a
tailor-made splint created by a hand therapist.
When the trigger nger is the thumb, the splint
puts the IF joint of the thumb in extension. It can
be a static splint if the IF joints reaches 0° of
extension with no stiffness and pain, while it
must be a dynamic splint when the IF presents
more stiffness or it is not possible to put it at 0°.
In some painful cases the therapist can provide a
static splint in the beginning and then convert it
into a dynamic splint when pain is reduced and
the child gets used to wearing thermoplastic
splints.
The static splint is made of thermoplastic, and
it is anti-brachiometacarpal with a dorsal component for the thumb that puts in extension both
MCP and IF joints (Image 34.12).
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Image 34.12 Static splint for thumb
Image 34.13 Dynamic splint for thumb
The dynamic splint has an elastic traction for
the IF joint, made with an elastic band: it is
important to create a gentle traction that can be
tolerated for a long time, more than a strong traction that the child cannot stand for more than a
few minutes (Image 34.13).
Image 34.14 Static splint for long ngers
When a long nger is affected, the conservative splint puts in the best extension the involved
structures: neutral wrist, extension of MCP, PIP,
and DIP joint (Image 34.14).
In our experience splints are more effective
and if the wrist is included and put into a neutral
position, they are more stable especially for the
younger patients.
Splint must be worn during the night and during the afternoon nap; it is more effective if it is
worn for at least 8h: day by day parents are recommended to increase the time of wearing.
34.6.2.1 Passive Mobilization
andStretching
MCP and IF joints must be mobilized to reduce
stiffness. It is important to prevent stiffness and
deformities to allow a better tendon sliding and to
improve PROM/AROM.
Stretching in extension for MCP and IF joints
is useful to reduce contraction in exion of the
involved joints, to improve tissues elasticity and
tendon gliding.
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