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34 Rehabilitation in Congenital Hand and Forearm Defects: Rehabilitation of the Child’s Hand—General…
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The therapist does it during the rehabilitation
session and teaches parents how to do it at home
often during the day.
34.6.2.2 Tendon Gliding
The therapist creates exercise and activities to
improve exor tendons gliding and to stimulate
extensor tendons. When long ngers are involved,
the complete exion is not recommended.
34.6.3 Taping
Kinesio taping could improve extensor tendons
work in order to reduce exion contraction.
Children can wear it all day long during their
daily activities.
The conservative treatment must be periodically evaluated and reviewed by the surgeon and
therapist, the splint in fact has to be checked, the
stiffness can decrease, and the growth of the hand
can change the tractions.
34.6.4.1 Edema andPain
Management
After surgery children are allowed to move and
use their hand without pain. The day after surgery
the therapist must check the bandage and in case
of important edema it is important to change it, to
allow a correct healing. Global active and passive
exercises can be taught and elastic bandage or
kinesio taping can be used to reduce edema,
where necessary. Every exercise and activity
must be done without pain. Ice and rest position
can be useful to reduce pain, in alternation to
active moments.
34.6.4.2 Active Mobilization
andTendon Gliding
Simple active exercise can be requested to the
child to evaluate and improve hand use. Selective
tendon gliding exercises are very important to
prevent tendons adhesion while the scar is healing and will be started immediately (Image
34.15). Gradually exercises will be increased to
improve dexterity and strength.
34.6.4 Rehabilitation After Surgical
Treatment
Rehabilitation program must be started immediately after surgery to reduce edema and pain and
further complications.
Short-term aims:
– Reduce edema
– Reduce pain
– Promote global activity of the hand
– Improve AROM/PROM
– Improve tendon gliding
– Correct scar healing
Long-term aims:
– Maintain and improve AROM/PROM
– Improve dexterity
– Improve scar tissue elasticity
– Maintain and improve tendon gliding
Passive Mobilization andStretching
Reducing stiffness of the involved joints is important to allow a better active motion and a better
tendon gliding. Stretching must be gentle and
gradually more intensive for the involved joints
and tendons (Images 34.16 and 34.17).
Image 34.15 Scar treatment
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Images 34.16 and 34.17 FLP gliding and stretching
34.6.4.3 Scar Management
Scar massage must be started when the healing
is complete. It is very important to manipulate
the scar many times a day to have soft and elastic tissue. Stretching also increases skin elasticity. During the night a silicon band can be put
on the scar to improve the scar healing. Kinesio
taping and compressive elastic bandage can be
used for a few hours a day to maintain the scar
at and elastic. Sensitive rehabilitation is
started after skin healing to prevent sensibility
defects.
E. M. Mancon et al.
34.7 Syndactyly
34.7.1 Post-surgery Treatment
Syndactyly is one of the most heterogeneous
congenital malformations described in literature.
This malformation can be isolated or one of
the signs in a more complex syndrome, but the
surgical approach is the only one suggested. This
means that the rehabilitative approach is for postsurgery, and it begins the day of the surgery.
34.7.1.1 Time 0
Immediately after surgery the hand therapist has
to protect the structures that underwent surgery,
the ngers have to be separated, and the new
webs have to be protected but maintained deep
during the healing process. In the most severe
Image 34.18 Splint for syndactyly
cases the therapist can provide a splint in thermoplastic material on the dressing to wear during
the night, or also during the day if the bones were
involved too (Image 34.18).
Active movement will be promoted from the
very beginning, especially for the non-involved
structures, such as exion and extension of the
ngers.
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The dressing will be constantly checked; if the
hand presents edema it will be replaced, like the
splint if there is one in order to optimize the
results obtained with the surgery.
34.7.1.2 From theThird Week On
When the wound is completely healed the splint
has to be adapted to the new size, a smaller one.
The deeper part of the new web space that has
been created through surgery has to be pressed
properly to keep it wide and low; to do it on the
splint the therapist puts elastic bands like neoprene bands or thermoplastic saddle. The same
aim will be obtained also through a deep and
compressive massage with a cream or oil; this
massage will be taught by the therapist to the parents or caregivers during the rehabilitative sessions. The parents must massage the scars at
home for a few minutes but very often during the
day, to prevent the thickening of the scar and
most of all to prevent the web to become higher.
In addition, during the night, the use of silicon
sheets or elastomer is suggested under the splint,
to guarantee a good hydration that means a better
elasticity and a better movement of the involved
structures.
For the rst web a special saddle has to be
done by the therapist; in this case it helps to
widen the web, and to keep it low, normally during the rehabilitative sessions the saddle needs to
be modied.
In both cases, rst web or others, the little
patients will be involved in play activities to
involve the whole upper limb, the single segments to have a full recovery.
Taping (like kinesio-tape) can be useful to
correct the single digit or more of them if needed;
elastic compressive bandages can be used to
increase the width of the web or to compress
hypertrophic scars.
In case of slight stiffness in exion of the ngers it is possible to create static splint to promote extension. In most severe cases a dynamic
splint can be suggested, with a more precise,
strong perpendicular traction on the nger.
The child during the therapy will use both
hands or only the operated one to easily adapt to
the new situation; obviously the activity that the
therapist proposes will be different from a child
to another, considering the age and what the
patient likes most.
It is important to underline that parents or
caregivers must engage time at home to go on
with the therapy, the massage of the scars must be
done at least 4–5 times a day (avoiding “rubbing”
the scar), the splint needs to be worn every night
for at least 3–4 months, and daily the child has to
be encouraged in the use of the single hand and of
both of them during ADL and games. Only in this
way the child is able to corticalize the “new
hand” and its new possibilities.
34.8 Symbrachydactyly
34.8.1 Introduction
Patients affected by symbrachydactyly can present different phenotypes; Blauth’s classication,
modied by Foucher, provides a valid guidance
for treatment.
In stage I therapeutic indication is to separate
any possible syndactylies with consequent lowering of the interdigital webs (see the
introduction).
In stage II therapeutic indication is to stabilize
digital segments with bone hypoplasia with free
phalanx transfer from the foot.
In stage III therapeutic indication is, where
possible, phalanx transfer from the foot or toe-tohand transfer; in the monodactylous type it can
also be necessary to improve the position of the
rst nger with web correction or bone
lengthening.
In stage IV there are no specic therapeutic
indications.
34.8.2 Phalanx Transfer
The little patients affected by symbrachydactyly
phenotypes 2a, 2b, and 2c have surgery indication of free phalanx transfer.
After surgery, the child has a cast immobilization for 4 weeks: it includes the wrist and the
operated ngers up to the tip.
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E. M. Mancon et al.
The therapist has to give the child the correct
stimuli to increase both bimanual grip and the
pinch with the operated hand; so we focus on preventing the exclusion of the operated hand and, if
an opposable segment is present, we stimulate it
to increase its functionality.
It is important to work with objects with different shapes, dimensions, textures, and material
surfaces to arouse sensibility of the transferred
toes. Whether the patient had already developed
an autonomous path prior to surgery, it is also
important to do a walking training to balance the
weight distribution and to re-establish the biomechanics of the step; otherwise it is advisable to
follow the patient during the development of
motor skills which involve passing to the standing position and then to the path.
Rehabilitation goals after toe-to-hand transfer
are divided in short-medium term and long-term
goals.
Image 34.19 Scar treatment
After 4 weeks the patient has a change of
dressing under anesthesia and the cast is removed.
At this stage the therapist makes a handmade
removal splint with thermoplastic material that
includes the wrist and with a protection above the
toes that had surgery.
From week 4 the therapist can start working
on bimanual grip stimulus through games to
include the operated hand and stimulate active
mobilization via the grip of objects of different
shape, dimension, and texture.
Also it is important to do the scar massage to
prevent scar adhesions (Image 34.19).
It is essential to maintain long-term follow-up
to monitor bone growth by surgeons; quite often
it is necessary to do a web lowering.
34.8.3 Rehabilitation After Toe-to-
Hand Transfer
• Short-medium term goals: 0–8 weeks after
surgery
– Vitality of the transferred toe
– Edema control
– Integration of the limb and the transferred
toe
– Increased active and passive range of
motion
– Sensibility development
– Corticalization progress
– Correct weight distribution and walking
path
• Long-term goals: over 8 weeks from surgery
– Transferred toe integration during daily life
activities
– Increased active and passive range of motion
– Sensibility enhancement
– Strength increase
– Corticalization progress
– Autonomous path
Early rehabilitation program:
The pediatric hand therapist will follow the little
patient during all the therapeutic period and will
teach the parents how to manage and rehab both
the hand and foot at home.
• Day 0–3: immobilization
– Child is hospitalized.
– Cast immobilization.
– Constant vascular check by surgeon.
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• Day 3–7:
– The child is still hospitalized.
– Constant vascular check by surgeon.
– First approach with the physiotherapy
department.
– Integration of the limb through games with
particular attention on the transferred toe.
Our rehabilitation program begins during the
rst week after surgery, compatible with the vascular check of the transferred toe and preserving
bone synthesis, and tendon, nerves, and vessels
sutures.
The donor site is immobilized with a cast up to
the knee and the load is not allowed to guarantee
the healing of the intermetatarsal ligament
between the rst and the third metatarsal bone,
after the removal of the second ray. The upper
limb is immobilized with a cast from the elbow to
the ngers included, to protect bone synthesis,
vessels, tendons, and nerves sutures. The transferred toe tip remains uncovered to monitor its
vascularization.
Image 34.20 The post-medication splint
During the week after surgery the child has the
rst approach with the rehabilitation department
and the therapist, in order to know each other and
to establish the trust relationship between the
therapist, the patient, and, in this case, the
patient’s parents. Rehabilitation takes place
through games and bimanual activities, to avoid
limb exclusion and to keep the elbow and the
– Passive mobilization of the PIP and DIP
joints
– Active recruitment both in exion and
extension
– Sensibility stimulation
– Walking training with casts
– Scar treatment, when possible
shoulder joints free. If the patient is compliant, it
is important to bring since the very beginning the
child concentration on the transferred toe to start
the integration process. At days 7–10 after surgery, the patient has a change of dressing under
anesthesia. Both to the hand and the donor site:
the hand cast is removed and replaced by a handmade removal splint in thermoplastic material,
with the wrist included and a protection above
the transferred toe (Image 34.20).
During these weeks the patient has physiotherapy every day. The splint is removed during
physiotherapy and at home when the child is
under parental control.
To limit the exclusion of the operated limb due
to the defensive mechanisms, the therapist has to
promote bimanual activities through games. Also,
it is important to maintain free shoulder and elbow
joints and their muscular mass, in order to limit
damages from non-use hypotrophy.
• Day 7 to week 4: passive mobilization of the
PIP and DIP joints, sensory stimulation, active
recruitment
– Bimanual activities
In this stage, the therapist begins passive
mobilization of the PIP and DIP joints, as they
are distal to the bone synthesis, with the aim of
preventing joint stiffness, increasing their passive
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abc
Image 34.21 (a–c) Active recruitment and stimulation
E. M. Mancon et al.
range of motion and promoting passive tendon
sliding.
Moreover, the therapist will stimulate active
recruitment both in exion and in extension,
always through games and modulating the rehabilitative requests based on the child’s age and his
interests and preferences; it gives an initial cortical motor scheme, making the child focused and
conscious on his transferred toe (Images 34.21a–
c and 34.22a–d).
It is important to introduce a sensibility stimulation program as soon as the skin allows it. In
fact it has been demonstrated that foot toes can
recover a greater degree of discrimination when
transferred, than those that are not transferred.
Also, the cortical representation can be modied
when receiving peripheral inputs and therefore
working on sensibility on early stages led to an
earlier and better recovery.
Scars treatment includes compression massages, lifting to prevent adhesions, and silicone
patches at night.
The donor site has been immobilized for 4
weeks by a proper splint with a raised part to
avoid weight on the forefoot. Therefore the therapist must train the child how to walk with the
cast, focusing on the correct weight distribution
and the gait pattern, to prevent secondary damage
from incorrect walking scheme and non-use
(Image 34.23a, b).
From week 4 to K-wire removal: electrostimulation introduction and increase in functional
demand
• Bimanual activities
• Passive PIP and DIP joint mobilization
• Active recruitment both in exion and in
extension
• Sensory stimulation
• Scars treatment
• Electrostimulation
• “Exergames”
• Walking training
• Psychomotor therapy
The physiotherapy sessions can now be intensied and we also introduce psychomotor therapy twice a week (see Sect. 34.16).
During physiotherapy we prosecute with passive and active mobilization of synthesis-free
joints, as well as sensory stimulation.
As soon as the vascular stability is achieved
and the surgeon gives the consent, it is possible to
work on the edema control with elastic compressive bandages or with Kinesio Taping®.
The immobilization period of the lower limb
lasts for 4 weeks. After this, the therapist has to
reeducate the child to the correct load distribution
during standing position, then walking, according to the gait biomechanics, and eventually run-
bc
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a
d
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Image 34.22 (a–d) Activities for hand movement
ning and jumping. On the other hand, if the child
in the preoperative period had not yet achieved or
completed the motor skills of walking, the therapist should favor the postural steps that lead the
child to reach the standing station with the correct weight distribution on the donor foot and
then the walking scheme, involving also parents
and teaching them how to stimulate the child at
home.
Subsequently, variable stimuli for stability
and foot support surfaces are provided to increase
adaptability, coordination, and balance.
From week 8 the patient will introduce the use
of the electrostimulation once a day on the exor
tendons of the transferred toe.
The stimulus is used above all as biofeedback,
trying to provide the child the sensation determined by the contraction of the exor muscles
and consequently the movement at the level of
the transferred nger to promote corticalization
processes.
Moreover, an increase on the intensity of the
electrical stimulus will increase muscle strength
to obtain a more efcient movement. The thera-
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Image 34.23 (a, b) Scar treatment of the donor site
E. M. Mancon et al.
pist to correctly set the work must talk with the
surgeon to have specic indications about the
course of the sutured muscles and tendons. Once
it is set by the therapist, the patient will perform
electrostimulation daily at home.
Rehabilitation requests must always be proposed in the form of play, according to his fantasy and preferences, also using modern
technology. In our department we introduced the
use of the “Exergames,” an electronic device that
stimulates coordination and the capacity to modulate pressure intensity and movement wideness.
These tools help the corticalization process and
facilitate the integration and use of the transferred
toe. Nowadays, we can consider them a new
endearing rehabilitative experience for our little
patients.
• From K-wire removal:
– Scar treatment
– AROM and PROM increase (including MP
joint)
– Sensory stimulation
– Strength training
– Coordination and dexterity
– Psychomotor therapy
After X-ray control by the surgeon approxi-
mately 8 weeks after surgery, the patient has a
change of dressing under anesthesia to remove
the Kirschner wire.
After this, the patient will continue physio-
therapy and psychomotor therapy regularly.
At this stage, passive and active mobilization
has no limits also concerning the metacarpophalangeal joint. If necessary, the therapist can make
a dynamic splint to increment exion due to
residual joint stiffness or tendons adhesions.
Sensory stimulation program become increasingly complex and exercises are modulated
according to the sensitivity improvement. The
patient will continue electrostimulation daily for
3 months from surgery. Rehabilitation will now
be focused on implementing coordination, dexterity, and ability in grasping objects with different shape and dimensions.
34.9 Polydactyly
34.9.1 Radial Polydactyly
Radial polydactyly is the form with the largest
number of presentation variants ranging from a
duplication of the distal phalanx to a triphalangia.
With this variable presentation framework, it is
necessary to know the type of surgery carried out.
If only the supernumerary segment has been
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a b
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Image 34.24 (a, b) Radial polydactyly in bilateral case: pre- and post-surgery
removed, if a ligament reconstruction has been
performed, if the patient has been subjected to
tendon disruptions and shifts or cuneiform osteotomies. The primary objective in the immediate
postoperative phase is to protect the structures
involved in the surgery through a child-tailored
splint. Subsequently, a protected mobilization
protocol will be started to resume the mobility of
the rst nger and reeducate it for use in gaming
activities (Image 34.24a, b).
Below we describe the rehabilitation phases.
physiotherapy and in safe situations. The
splint will slowly be weaned during the day. In
the case in which in the surgery a ligament
reconstruction has been performed, the oper-
ated segment will be protected for another 2
weeks.
• Mobilization of the interphalangeal and meta-
carpophalangeal articulations in exion and
extension paying attention to deviations. It is
also important to stretch the rst web and
work to open it to encourage the opposition. It
is crucial to teach the parents how to do those
34.9.1.1 0–4 Weeks
• Immobilization with a splint in opposition and
abduction of the thumb.
• At the end of the fourth week the dressing is
performed and an anti-brachiometacarpal
splint is packaged with long ngers free and
the rst ray positioned in opposition.
exercises at home.
• Scar treatment with the application of silicon
patches on the same during the night under the
splint. It is possible also to package a saddle
splint for the opening of the rst web in order
to avoid the formation of an hypertrophic or
retracting scar that could severely restrict the
free movement of the rst ray, in particular in
34.9.1.2 4–6 Weeks
• The splint is converted in a removable one that
will be removed in a rst phase only for the
grip activities.
• Prevention and correction of any deviation
through the use of splints or the application of
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Kinesio Tape® with functional correction
technique.
• Game activities for the stimulation of the
bimanual grip.
34.9.1.3 6–8 Weeks
• The splint is abandoned during the day and
maintained for the night. It is still important to
value the position of the nger and the scar
trophism before taking any decision.
• Proposal of various recreational activities to
stimulate the grip between the thumb and long
ngers (pinch and tridigital grip) such as
drawing and the use of constructions or
puzzles.
34.9.1.4 8 Weeks
• If there is stiffness of the MCP’s joint due to
the scar a pro-exion dynamic splint can be
packaged (Image 34.25).
Image 34.25 Dynamic splint for MCP exion
34.9.2 Central Polydactyly
Central polydactyly, or synpolydactyly, is a hand
malformation affecting the central segments of
the hand. It presents itself as a fusion of the central elements with the presence of a supernumerary segment that can be presented in various
forms of conformation and development.
The presence of a central supernumerary segment leads, in the majority of cases, to an alteration of the adjacent joints. Postoperative
rehabilitation following surgical removal of the
segment therefore has, as its primary objective,
the recovery of the articular excursion of all the
joints of the hand and the stimulation of the use
of the hand and especially of the grip.
Below we describe the rehabilitation phases.
34.9.2.1 0–4 Weeks
• Immobilization with a compressive dressing
and pinstripe valve.
34.9.2.2 4–6/8 Weeks
• A protection splint is packaged to protect the
operated structures allowing the mobilization
of the not involved segments. The splint is
used during the night and for not-safe activi-
ties for the rst period and then is weaned
gradually.
• Treatment of edema, in particular with Coban
dressing.
• Scar treatment to prevent the formation of
hypertrophic scar that will reduce the opening
of the web creating a limitation of articular
mobility. As soon as the wound is cured, an
elastic component is applied on the splint that
can allow a compression on the scar and an
opening stretching of the web (Image 34.26).
• Mobilization of the various articulation
involved and instruction of the parents to per-
form it at home.
• Proposal of recreational activities that allow
global hand mobility, encouraging movements
of long ngers and manipulation activities to
stimulate grip development.
• Diurnal syndactyly between the operated n-
ger and one of the adjacent ngers to avoid
any deviations and the exclusion of the oper-
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