Therapist`s Management of Fractures of the Hand
Transcription
Therapist`s Management of Fractures of the Hand
Therapist’s Management of Mallet injury, Jersey Finger, Pseudo-boutonniere, and Skier’s Thumb Julia Guthart, OTR/L CHT 1 Mallet injury 2 Therapist’s care of Mallet Injury: • Non-operative: Splinting • Surgical: – Closed reduction percutaneous pinning (CRPP) – Splinting 3 Non-Surgical: Splinting • Pre-fabricated • Stack splint • Alumifoam • Custom • T-shape • L-shape 4 Custom Mallet splints: T-shape L-shape 5 Mallet showing slight hyperextension at DIP 6 Use coban to secure 7 Check PIP joint flexion 8 L shape pattern 9 Check PIP joint flexion 10 Treatment • Instruction in support of DIP Joint at all times – While splint is off must hold DIP joint in extension – i.e. with other hand, with thumb, with table top • Attend therapy for weekly “splint checks” • Or attend therapy for splint adjustments PRN • Make sure PIP joint has full flexion; if lacking full PIP motion, need therapy more often • After 6 weeks, wear splint at night only 11 After 6weeks • If droop is reduced, can begin AROM • No passive flexion of DIP joint 12 Post-Surgical Care of Mallet Fracture • Splint to support DIP joint • Splint must protect pin • Active and Passive ROM to PIP joint and MCP joint • Splint can be removed for exercises • Instruct in Pin Care; provide pin care 13 After Pin Removed • ROM exercises • Desensitization of fingertip • A mallet splint/DIP gutter splint is fabricated for night time wear and between exercise sessions. 14 Goals of therapy • Full extension at DIP joint; extensor lag less that 10 degrees is acceptable • Gradual DIP joint flexion 15 Complications • Individuals with laxity at PIP, or hyperextension, may need extra splint at PIP joint to help balance extensor mechanism • Pin track infection • Non-compliance; MUST ALWAYS KEEP DIP JOINT EXTENDED FOR SIX WEEKS • Late-treatment, after sports season is over 16 Jersey Finger • Also known as Flexor Digitorum Profundus rupture with avulsion fracture • Treated as flexor tendon repair • Has “button” or stitch through fingernail 17 Therapy for Jersey Finger • Begin therapy post-op day three • Remove bulky dressing; re-dress with lighter dressing • Fabricate Dorsal Block Splint • Passive controlled motion program or a modified Duran program • Wound care and edema care 18 Jersey Finger Post-op Day 3 19 3 days s/p to 3 ½ weeks • PROM exercises are continued • Scar pad fabricated or applied when sutures removed and scar line dry • Keep edema under control • Can add active flexion and extension within the DBS (splint) at 3 ½ weeks if approved by surgical repair 20 Dorsal Block Splint 21 4 weeks • Add ultrasound if necessary • Add NMES (after active flexion exercises for 35 days) if re-education necessary • Add AROM out of splint; tendon gliding exercises • Follow protocol for remainder of weeks 22 Complications • • • • Scar tissue impedes tendon excursion Rupture Co-morbidity issues of poor healing Patient non-compliance with splint wearing and home passive exercises 23 Pseudo-boutonniere • Due to PIP joint injury – Dislocation with hyperextension – Central slip injury – Volar plate injury – Most commonly due to “jammed finger” left undiagnosed 24 Definition pseudo-boutonniere • PIP joint flexion contracture with the DIP positioned in extension • The DIP joint is passively flexible with the PIP joint extended • In a true boutonniere the ORL is not flexible so cannot passively flex the DIP joint 25 Therapist’s treatment: • AROM and PROM DIP joint • AROM and Passive Extension PIP joint • SPLINTING: dynamic and/or static progressive 26 Splinting for PIP joint • A dynamic splint for on/off during day OR • A static-progressive splint for on/off during day • A static extension splint for night time 27 Dynamic PIP extension splints • Pre-fabricated splints for PIP extension such as the LMB or joint jack or reverse knucklebender • Custom hand based PIP joint extension splint with outrigger 28 Static progressive PIP extension splints • Custom “PIP Keeper” • Serial cylindrical casting 29 Exercise splint • Keeps PIP joint in extension while patient flexes DIP joint • Helps with blocking exercises 30 Complications • It is difficult to obtain end range PIP joint extension • PIP joint may appear “flexed” due to fusi-form shape of edema • Patient non- compliance with therapy and all the splints and schedules 31 Thumb: MP joint Ulnar Collateral Ligament injuries or Skier’s thumb • Incomplete rupture = sprain; therefore splinted for 4 weeks • Complete rupture with Stener’s lesion= surgery with pinning of MP joint; without avulsion fracture, internal anchor or suturing 32 Thumb UCL sprain • Hand based thumb spica; IP free or included depending on age of patient and lifestyle i.e. if student or athlete, hand based thumb spica to the tip with patient removing splint for IP joint flex/ext only • Will need to assess fit of splint and possibly remold splint due to edema loss • No therapy to MP joint for 4 weeks 33 Thumb UCL repairs • Pin to secure rupture of avulsion fracture OR internal anchor • Custom splint fabricated at 10 to 14 days after surgery • Thumb spica forearm based; if a pin is present, therapist must bi-valve the splint for on/off • IP joint is free 34 Therapy for Thumb MP joint UCL • At 4 weeks can start AROM of MP joint; avoid stress to UCL (such as stretching open thumb web space activities) • At 6 weeks can start AAROM of MP joint; at 7 weeks can add PROM to MP joint • Avoid weighted resistence or sustained power pinch until 14 -16 weeks 35 Complications • Pin track infection • Scar adhesions decreasing web space • MP joint extension lag is sometimes common at first • Patient non-compliance with splint wear, pin care, return to sports 36 Splinting Lab • Mallet splint • Dorsal gutter to PIP joint • Night time extension gutter 37 Other splinting slides • Just for fun! 38 Articular fracture with external fixator 39 Articular fracture with external fixator 40 Hand based safe position with bumper 41 Hand based safe position with bumper Two-piece splint held with velcro 42 P2 fracture with pins: gutter splint with birdcage 43 P2 fracture with pins: gutter splint with birdcage 44 45 P1 fracture with ORIF s/p day two 46 Hand based Ulnar gutter 47 Hand based Ulnar gutter Small finger DIP free Ring finger PIP free 48 Multiple fractures 49 50 51 52 Questions/Discussion Contact information: [email protected] Phone: 858-7045 53
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