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34 Rehabilitation in Congenital Hand and Forearm Defects: Rehabilitation of the Child’s Hand—General…
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a b
Image 34.40 (a, b) Splint in abduction and external rotation of the humerus and stretching of the interrotators
abc
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Image 34.41 (a–c) Tutor in extension of wrist in p.o C5 C6 C7
Image 34.42 Appearance of the biceps activity after 3 months after birth. (a) At birth. (b) After 3 months
moment. As such its aim is to optimize the recovery of the upper limb’s mobility.
For some children, recovery is spontaneous.
For others surgical intervention is necessary and
it is the therapist’s job to set the conditions to
reach an optimal result.
During this stage it is necessary to educate
parents on the desirable objectives of the surgery
and on the meaning of each rehabilitative step
after the surgery. Parents’ collaboration is fundamental to obtain constant mobilization and stimulus for the young patient.
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Image 34.43 (a–c) Passive mobilization
E. M. Mancon et al.
The therapist has to give parents a written and
personalized program. This program includes
home rehabilitation exercises, the position of the
upper limb, and the correct activities for a specic rehabilitative moment and the physical
development of the child.
In the rehabilitative program games play an
important role. It is in fact not possible to have a
classic program based on mobilization and
strength exercises. The therapist will have to
develop a specic play-based program taking
into consideration the child’s physical and psychomotor abilities, which can change over the
course of the treatment.
All post-surgery treatments have common as
well as specic elements based on the surgical
technique used. Because of this it is necessary to
communicate with the surgeon about the patient’s
clinical picture and the anatomical structures
involved in the surgery, before preparing a
program.
Another important element to consider before
writing a treatment is the importance of the young
patient’s evaluation. This evaluation has to be
done constantly to verify the evolution of the
clinical picture and adjust the objectives of the
treatment.
It is hard to evaluate a child as he/she will
hardly remain in classical position for muscular
evaluation and even harder to comprehend muscles sensitivity. For muscular evaluation the therapist will once again have to use games and
activities that allow testing on major muscle
groups or once the child is a little older use sim-
ple exercises such as bringing a hand over the
head or to his/her mouth. As for muscle sensitivity the therapists will use a scale of evaluation by
Narakas; this scale evaluates responses to hurtful
stimulus on a scale of s0–s5.
Sensitivity is fundamental for functional
recovery: an arm that can’t feel, can’t be used, so
it will also be necessary to educate the child on
recognizing stimulus from different entities.
The last consideration has to be done to the
evolution of the body structure and has to include
the involved limb. If not correctly stimulated, the
child will likely exclude the limb from this structure. This will limit the possibilities of its functional use, no matter the post-surgery or
spontaneous regeneration of nerve tissues (Image
34.43).
34.13.3 General Principles ofPost-
surgery Treatment
Regardless of the type of surgical intervention,
whether primary or palliative, there are some
treatment elements in common to be considered.
First of all the idea of protection of the surgical seams. The seams, nervous, or the tendon
ones are less resistant and, under stress at an early
stage, they can break.
The rst aim of every post-surgery intervention is the protection of the seams. The strains
that can break the seams, frustrating the surgical
intervention, are strains in the hyperextension of
the nerve or of the involved mio-tendon unity.
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Therefore to protect means to put in damping,
i.e., in shortening the involved anatomic
element.
It is fundamental to know the anatomy and to
communicate with the surgeon to know the timing and procedure of mobilization that will be
specic for each surgical intervention.
During the immobilization period, it is important to supervise and to treat the edema, which is
an actual physiological glue that, if not treated
adequately, leads to retractions of the soft tissues
and joint rigidities.
To eliminate the edema, the parents must be
informed about the correct placement of the limb
that must be kept raised up as much as possible,
about the icy applications that must be carried out
many times a day for at most 20min, and about
the early mobilization of the joints not involved
in the intervention.
Moreover during the period of immobilization, the parents must be taught about the supervision of the plastered device or of the xed tutor
that must not cause reddenings or secondary
damages to the skin.
In this period it is suggested that the therapist
supervises the baby once a week to verify the correct placement of the xed tutor as well as its
tolerability.
At the removal time, the therapist sews a
removable tutor that usually proposes the same
position of damping given during the
immobilization.
This tutor will be initially removed only for
the daily hygiene or for the physiotherapy and it
will be gradually left, with specic timing and
procedure based on the type of intervention.
During this phase, the scar treatment starts. It
is fundamental to prevent adhesions with the
underlying tissues and to avoid problems of scarring hypersensibility.
It is important to teach the parents about the
scar tissue release massage that must be carried
out ¾ times a day with the use of cream for
10 min each. If the scar becomes hypertrophic
the use of little sheets of silicone or elastic compressive sheaths is suggested, whereas in case of
adhesive scars the negative syringe that plays the
function of vacuum therapy is used.
In children, as the cellular hyperproduction,
the formation of hypertrophic scars is easy, which
must be treated and eliminated as soon as
possible.
The treatment of desensitization establishes
the use of gradually more rough surfaces that
must be rubbed on the whole hypersensible zone
in order to bring sensibility threshold back to a
normal level.
Besides the scar treatment, a program of protected mobilization takes place, i.e., an analytical
joint mobilization which maintains still in damping (in shortening) the involved structures. These
structures will be stimulated during the following
weeks.
In this case too, timing and procedure of protection change according to the surgery
technique.
One important thing to remind is that after the
primary intervention, nervous graft of neurotization, and after the period of immobilization, the
active motility is overlapped to the previous one
before the intervention.
To observe change in the clinical situation, we
must wait for the reinnervation period, whereas
in case of mio-tendon transfer we could notice
the results after the immobilization period,
because a functioning muscle has been moved to
obtain the missing function. It is fundamental to
communicate this to the parents who must not
have false hopes after the primary intervention, in
order to be motivated in carrying on the
treatment.
Another important principle in the recovery of
the functional contraction: in case of primary
intervention, we must evaluate the different muscle groups that regain their functionality based on
the nervous regeneration, whereas after the transfer it is necessary to teach the child how to recruit
the muscle that carried out a different function and
how to recover the one that was missing before.
In the reinforcement program of the denervated muscle that is gradually reinnervated, we
have to remind that at the beginning the muscle
will be able to carry out only isometric contractions and only with time isotonic contractions.
All the neuromuscular techniques of facilitation must be used that lead spontaneously or with
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E. M. Mancon et al.
reection the active contraction in the involved
muscle. Techniques like tapping, the brushing of
the muscular stomach, etc. can be carried out,
and above all games that allow the baby to recruit
the involved muscular groups.
Electrostimulation must be mentioned, but it
is very much discussed in literature, in particular
in children’ treatment.
Regarding the primary intervention, the only
possible indication is the use of e.s. with exponential streams, to be applied during sleeping
with the only aim of maintaining the trophism of
the denervated bers waiting for the reinnervation. In case of transfer the use of rectangular e.s.
is suggested, indeed, in the pre-surgery treatment, with the aim of reinforcing the muscle to
move that is going to lack a grade in the scale
m0–m05 of strength, once moved.
For the recovery of function besides movement the recovery of sensibility is fundamental.
In case of obstetrician lesions, it is more correct
to speak of education to sensibility, because the
involved parts have never been experimented to
have any kind of sensible perceptions.
The treatment considers the brushing of
objects and tissues of different consistencies on
the on the cutaneous zones involved in the lesion.
We must remember that the child’s competences
evolve with his growth. Indeed, a child learns
how to recognize an object at the age of 4–5 and
he learns to discriminate due dots at the age of 9.
We have to try to reactivate the sensibilities,
reminding that the proprioceptive is supported
also by the passive mobilization, which has a
double role: maintaining the PROM and sending
proprioceptive important information or the integration of the limb in the body scheme during the
growth.
In all the post-surgery treatments the use of
tutor that plays different functions according to
the specic rehabilitative phase is useful.
They can be used in place of the plaster cast
during the immobilization period, with the advantage of being light weight, transpiring, and hence
much more tolerable by the patient; they can be
also used as a prevention tool or to correct rigidities (for example static tutors that maintain the
wrist in extension or the hand in safety position
in case of total lesions, or in the treatment of the
rigidities of the elbow, tutors that ex the elbow
gradually that tends to the extension position, to
inhibit the activity of the triceps during the period
in which the biceps activity is absent or lacking).
Another function of the tutors is helping in the
use of the limb involved in the lesion: for example in case of an approximal recovery of the
shoulder but not distal of a hand, a tutor for the
wrist with an applied Velcro on which anchor
games help the child in the use of the damaged
superior limb in the bimanual grabs, using the
paretic hand as a passive grab, or in case of ipo
activity of the triceps, it is possible to tailor a
tutor in extension of the elbow to facilitate the
quadrupedal stand and so stimulate the child to
creeping.
Thanks to this, besides helping the psychomotor development of the child, we stimulate the
recruitment of the muscles of the shoulder girdle
thanks to the load induced by the superior limb in
stand.
In case of untreatable rigidities through passive mobilization, it is suggested to tailor dynamic
tutors that keep the retracted pericapsular structures in a gradual traction as well as the tendon
structures that are tight to the adjacent tissues.
The tailored tutors for children must be stuffed
to avoid cutaneous ulcers and they must be modied over time, according to the child’s growth or
to development of the clinical situation (Image
34.44).
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Image 34.44 (a–c) Preventive splints: rest position
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34.14 Thumb Hypoplasia
andPollicization
Thumb hypoplasia and thumb agenesis represent
at the same time the more compromising malformations for hand usage, but also those with more
reconstructive surgery options with good results.
In fact, in several forms the results obtained
with the surgery have acceptable morphological
and functional aspects.
On the basis of pathology staging and surgical
options (see Chap. XX), the rehabilitation program will optimize and improve the results
obtained both in terms of aesthetics and
mobility.
Therefore, the rehabilitation program will be
personalized and adapted to the surgeon
indications.
The main goal is to improve and stimulate the
integration of the rst ray during game and keep
the rst web wide enough to allow the correct
grasping of objects with different dimensions.
The day of surgery the hand therapist made a
splint in thermoplastic material.
The day of surgery an immobilization splint is
packaged directly in the surgery room either by
the surgeon through a pinstriped valve or by the
therapist. After the change of dressing, which can
take place in deep sedation or in the clinic accord-
ing to the indications, a removable splint is packaged to allow the start of the mobilization and
rehabilitation protocol. The splint may have different characteristics depending on the surgical
technique performed, but it will always pursue
the objectives such as:
– Protection of the transferred/reconstructed
structures
– First web opening
– Comfort and ease of use for our little patient
and caregiver
34.14.1 Rehabilitation Protocol
Post-surgery inThumb
Hypoplasia
In the case in which surgery has been performed
to reinforce the thumb in the malformation of the
thumb hypoplasia, such as the tendons transposition interventions like the one according to Huber
Littler, the hospital protocol will pursue the following objectives.
In the immediate post-intervention we will
have to protect the transferred structures allowing
the correct healing in the position given by the
surgeon and avoiding stress on the transferred
tendons/muscles.
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A cast immobilization will be packaged to
keep xed for 3–4 weeks in position of opposition of the rst ray.
34.14.1.1 21 Days
Following the change of dressing a removable
splint is packaged (Image 34.45) to keep the rst
web well open and the thumb in opposition to
protect the transferred muscle. This splint is
removed during physiotherapy and in moments
dedicated to the re-education of the gesture, to
the functional recovery, and to the grip stimulus.
The rehabilitation sessions will take place
every day to teach the parents/caregiver the
appropriate stimulation techniques and at the
same time the rules for the protection of the
transferred muscle. Attention should be given to
stress-threatening moments for the transferred
muscle, for example during the child’s sleep and
free play, as well as if the small patient is in the
training phase of the walk because of the risk of
falling on the hands.
The treatment of the scar through manual
massages is very important to mature it elastic
and normotrophic. To limit the risk of pathological scarring, saddles in thermoplastic material or
tape will be used combined with a silicon patch
or elastomer compression able to keep open the
rst web (Image 34.46).
We will gradually insert exercises to stimulate
the grasping of objects of various sizes by taking
advantage of games and play activities based on
the age and predisposition of the little patient.
E. M. Mancon et al.
Image 34.46 Dressing with compression and rst web
opening
We can also use electrostimulators with lowintensity electrical stimulation to be applied to
the transferred muscle both as biofeedback to
stimulate the corticalization of the gesture and to
strengthen the muscle itself that, as we know,
once transferred partially loses its strength if the
lever of biomechanical action is modied (Image
34.47).
Image 34.45 First dressing
34.14.2 Early Rehabilitation
Program After Pollicization
The rehabilitation after pollicization has two
main goals: rstly, to protect the “new” thumb
and its sutures on tendons, nerves, veins, and
arteries and the stabilization on bones; on the
other hand, to stimulate active movement, sensibility recovery and its corticalization.
After surgery the patient wears a cast immobilization for 10 days; after this, the patient has a
change of dressing under anesthesia and the cast
is removed and replaced by a removable hand-
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Image 34.47 Electrostimulation
made splint in thermoplastic material. The splint
includes the wrist, with the MCP joint of the rst
ray included.
At the beginning the splint will be worn
always, except during physiotherapy and home
exercises, and it will be progressively abandoned
rst in the daytime hours.
The rehabilitation program lasts around 8
weeks, with daily sessions and specic exercises
at home. After the acute phase, physiotherapy
sessions will be complemented by psychomotor
sessions, to spur the correct development and
involvement of the limb in the pattern of movement of the correct age.
34.14.2.1 Days 0–10
Cast/splint immobilization with the wrist
included and the thumb in abduction and opposition (Image 34.48).
At day 10 the patient has a change of dressing
under anesthesia (to limit trauma for the child),
and the cast is removed and replaced by a removable handmade splint in thermoplastic material
Image 34.48 First splint
Image 34.49 Removable splint with reduced dressing
with the wrist included, the thumb in opposition
and abduction and its IP joint free (Image 34.49).
34.14.2.2 Days 10–21
The splint can be removed only for exercises of
assisted active mobilization of the rst ray, keeping it in an abducted position and avoiding lateral
deviation.
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Image 34.50 Games
During physiotherapy sessions we work on
passive mobilization and stimulation of active
recruitment of the IP joint with the use of targeted
recreational activities such as the functional grip
of objects of different sizes between the new
thumb and the second nger (Image 34.50).
The correct stimulation is fundamental because
the brain has to construct the motor image of the
neo-thumb (motor imaging) that did not exist
before the surgery; therefore it will be essential to
avoid since the beginning the establishment of the
pathological pattern of interdigital grip between
the second and third ngers. The therapist can use
a bandage to stimulate and favor the position in
opposition of the thumb (Image 34.51).
From day 21 up to the fth week, physiotherapy will continue with the stimulation of the use
of the rst ray, favoring the grip of objects of different sizes and shapes, also taking advantage of
the bimanual grip. This activity must be progressively increased and meanwhile the splint will be
Image 34.51 Taping to stimulate opposition of the new
thumb
abandoned from daytime also at home by
instructing parents or caregivers (Image
34.52a–e).
By the healing of the scars, its treatment
begins which involves both manual massage and
compression with elastomer and silicone patches
at night. At this stage taping can be placed directly
on the skin of the new thumb to stimulate through
biofeedback the good position in opposition and
the wide opening of the rst web.
Moreover, the therapist will mobilize globally
the new thumb in opposition.
We can also use a functional splint without
wrist include (Image 34.53).
From the fth week the splint can be com-
pletely abandoned in protected situations (meals,
games in a protected situation, hygiene, etc.) and
kept only for protection; it will still be worn at
night. Considering the best age for this intervention, between the 12th and the 18th month of age,
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a
b
cd
e
Image 34.52 (a–e) Examples of games
the moments at risk could be considered the
stages of crawling or rst steps to avoid excessive
trauma to the new thumb.
At this stage, you can also start to selectively
mobilize the MP and TM joints as well. From the
sixth week it is possible to make a dynamic pro-
exion splint in case of residual stiffness of the
MP joint; this is the most frequent event in case
of the pollicization of a camptodactyly second
nger (Image 34.54). If necessary, the splint can
be made to obtain a global exion of the
neo-thumb.
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Image 34.53 Functional splint for the day
E. M. Mancon et al.
34.15 Radial Cleft Hand:
Rehabilitation
Patients affected by radial club hand present different aspects which affect 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, reduced long
ngers AROM.The concomitance of these problems limits the chance to have a functional grip
and consequently it is essential to begin an early
rehabilitation program with continuous follow up to monitor the clinical conditions during the
growth.
The major problem during the growth of these
patients is the frequent recurrence of relapses that
may occur despite the surgery being performed:
this can be due to different causes linked both to
intrinsic factors such as the impossibility of
releasing radial soft tissues completely or extrinsic elements such as the scarce use of the 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 program begins taking
charge of the patient after the rst visit with the
surgeon. It is divided in two different approaches:
Image 34.54 Dynamic splint
• Conservative treatment: it starts immediately
after the visit and lasts in the preoperative
time.
• Post-surgery treatment: it starts after the
surgery.
In both the approaches 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 process.
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