Bone and Joint Surgery: Prevention and Management of Complications by Hand Therapy

24 Bone and Joint Surgery: Prevention and Management of Complications by Hand Therapy

24.1 Part A: Hand Therapy: Prevention and Management of Complications in Bone and Joint Fractures

Gertjan Kroon and Elske Bonhof-Jansen

Abstract

Common nondisplaced hand fractures without soft tissue injuries can be treated with cast immobilization or a protective or buddy splint. Complications such as joint stiffness, tendon adhesion, and nonunion or malunion are rarely seen. However, stiffness as complication can occur due to inadequate or prolonged immobilization. Complex fractures often require surgical treatment. In open or crush injuries, surgery can be considered to be a “secondary trauma” and potentially these injuries are prone to scar formation and motion deficits. To prevent and manage these complications, timely referral and close collaboration between hand surgeon and hand therapist is essential. Hand therapy focuses on safe, progressive motion with control of pain within the timeline of the healing process. This is done with the aim to provide the patient with functional use of the hand and to resume daily activities as quickly as the injury allows. This chapter provides insights into the tools available to the hand therapist to prevent and manage common complications after hand fractures.

Keywords: hand therapy, fracture, timing, communication, early motion, stiffness, splinting

24.1.1 General Principles

Timing of Treatment

When preventing or minimizing complications, the goals are to maintain joint and soft tissue mobility while protecting fracture stability. The risk of stiffness depends on the location and stability of the fracture and increases with concomitant soft tissue injury or surgery. It is known that the extent of soft tissue damage is directly correlated with functional outcome.1^,²^,³^,⁴ Also, patient factors such as higher age, comorbidities, smoking, and psychosocial context (e.g., pain, anxiety, or catastrophizing) can influence outcome negatively.⁵^,⁶ In case these negative predictive values are present, early and timely referral to hand therapy is essential to prevent stiffness. Unfortunately, rehabilitation after fracture stabilization is sparsely described in scientific literature. Hand therapy consists of supportive or protective splinting and exercises, allowing safe, progressive motion with control of pain, based on the stages of fracture and soft tissue healing. By embedding purposeful movements in exercises, functional use of the hand will be improved in order to resume daily activities, work, sports, and hobbies.⁷ Hand therapy is most effective when started in the first week after surgical fracture stabilization, since it is easier to prevent stiffness and edema in the initial phase of fracture and soft tissue healing. The greatest recovery of active range of motion is seen within the first 6 weeks.⁸ Common nondisplaced fractures without soft tissue injury are commonly treated nonsurgically with or without cast immobilization. Stiffness as complication can occur due to inadequate or prolonged immobilization. Hand therapy is not routinely indicated, as it may be expected that full range of motion will be restored within 2 weeks after cast removal. Informing the patients about goals, expected recovery time, and outcomes will improve self-management. However, when pain persists, or gain of motion or functional recovery is delayed, easy access to a surgeon or hand therapist is recommended.

Communication

Besides the technical aspects, communication is an important key to successful rehabilitation.⁹ Close collaboration between surgeon, hand therapist, and patient is essential for effective treatment. The hand therapist will need information on fracture stability in order to initiate an appropriate rehabilitation program within the most effective but safe limits of fracture management.⁷ Specifically, in cases where the surgical result is not optimal; for example, insufficient fracture stability, soft tissue weakness, perioperative or expected limited motion, and required splint support. In addition, patient information provided by surgeon and hand therapist can manage expectations and support the patients’ self-management. Topics are pain and edema management, specific exercises, allowed functional use, expected recovery time, and outcome.

24.1.2 Complications

In open or crush injuries, surgery can be seen as a “secondary trauma,” increasing the risk of scar formation and motion deficits. These risks, with associated costs, have to be considered in fractures where surgical management is not proven beneficial compared to conservative fracture management.¹⁰ This chapter will describe complications that can be prevented or managed by hand therapeutic interventions.

Infection

In percutaneous fracture fixation with Kirschner wires or external fixation methods, pin-track infection may occur in 6 to 7% of cases.¹¹^,¹² In the majority of these cases, infections were superficial and resolved by oral antibiotics or removal of the infected pins. There is insufficient evidence that warrants a specific pin-site care strategy to minimize infection rates.¹³ Risk factors that predispose an individual to a pin-site infection has not been determined yet.¹² Due to a lack of evidence, general strategies to reduce the infection risk are advised.¹³ The hand therapist can inform the patient of infection prevention and give instructions for wound inspection to monitor for signs of inflammation.

Nonunion/Malunion

Local forces surrounding a fracture will influence bone generation.14 Excessive strain will result in nonunion or malunion, taking into account the tendency of the fracture to deviate in a potentially instable fracture.⁷ Fracture stability allowing active motion is assessed by the surgeon. When additional support is required during the first month, a three-point splint can be used in metacarpal fractures, a dorsal intrinsic plus splint in proximal phalanx fractures (Fig. 24‑1) and a dorsal finger splint in midphalanx fractures (Fig. 24‑2).

Fig. 24.1 Intrinsic plus immobilizing/exercise splint.

Fig. 24.2 Finger immobilizing/exercise splint.

In case of intra-articular fractures, protected early motion will prevent joint stiffness and optimize remodeling of the articular surface. Insufficient stabilization or using too much force in the early stages of fracture healing may lead to nonunion or malunion. In stable hand fractures, buddy splints may be used to prevent forces from causing deviation during the early phase of fracture healing.

Tips and Tricks

●Absence of pain and tenderness at the fracture site on palpation is a clinical sign of fracture healing.¹⁵

●Early motion supports fracture healing and reduces edema.

●Scissoring of the fingers can be a sign of malrotation or a muscle imbalance; assess the intrinsic muscle function (intrinsic tightness or loss of coordination) to differentiate.

●Use additional splint support in case of insufficient stabilization to allow early motion with X-ray check-up to assess fracture alignment.

●Provide practical patient information on do’s and don’ts in functional use in order to prevent overuse.

Stiffness

General

The cause of stiffness is often multifactorial. Initially, stiffness is due to edema. When edema is not controlled, the hand positions itself in metacarpophalangeal (MCP) joint hyperextension and proximal interphalangeal phalanx (PIP) joint flexion. This will lead to shrinkage of capsule and ligaments. Stiffness may also be due to arthrogenic limitations, resulting from either the trauma itself or from prolonged immobilization with capsule and ligament shrinkage. Adhesions may prevent tendon gliding or restrict motion. Shortening of bone may lead to a misbalance of the muscle/tendon complex. Finally, psychosocial factors should not be underestimated,⁶ since pain and fear to move or to use the hand during daily activities may also be a cause of stiffness, and overuse may cause swelling.

Joint Stiffness

Joint stiffness is characterized by MCP extension and IP flexion with limited range of motion in opposite direction. Often there is no obvious difference in active and passive joint motion. The opposite position, also known as “intrinsic plus position” or “the position of safe immobilization,” can prevent stiffness by positioning the joint ligaments in elongated position. Here, the MP joints are positioned in 60 to 70 degrees of flexion and IP joints in 0 degrees of extension. Prevention of contractures starts with positioning the joints in this position.

A combination of early controlled motion and intrinsic plus splinting during rest is indicated for all stable fractures that show a tendency of stiffness.

A dorsal intrinsic plus splint is able to support insufficient fracture stability, allowing early active motion (Fig. 24‑3). For postoperative PIP flexion due to hydrops, step-wise redressing to intrinsic position combined with active range of motion exercises is recommended. In case of intra-articular fractures, it is recommended to keep the immobilization period as short as possible. Recent literature shows that treatment with a dorsal intrinsic plus splint (restricting MCP extension when allowing full range of motion of the PIP joints) is safe in proximal phalanx fractures and prevents range of motion limitations.¹⁶

Fig. 24.3 Exercise with splint support.

When joint stiffness occurs, static progressive splints and sometimes dynamic mobilizing splints can be used around 6 weeks in fractures with enough structural strength; after which this may be alternated with a blocking splint to stimulate movement during activities in the limited direction. Relative motion splints are a user-friendly and effective supplement to support and improve active range of motion. If PIP flexion contractures occur, serial casting is indicated when other treatments have failed to regain extension; be sure that there is no flexion deficit prior to casting.

Tips and Tricks

●Control edema with pressure therapy (elastic-bandage wrapping or a pressure glove), elevation and massage.

●When immobilization is indicated, use intrinsic plus position.

●Use an intrinsic plus splint combined with early active motion in case of stable fractures.

●Use a mobilizing splint around 6 weeks in case of joint stiffness, if consolidation is confirmed, and alternate with active motion.

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