Clinical Factors Defining Relative Stability of a Fracture
Which bone; where in bone
Nature and number of fracture line(s)
Initial fracture displacement and alignment
Type of reduction and fixation
Postreduction and fixation alignment
Nature of additional soft tissue injury
Time since fracture/surgery
Normal daily functional demands and priorities of the individual
Essential Elements to Gaining This Understanding
Referral: Complete and detailed fracture information
Imaging: Pre- and postreduction fixation imaging
Operating Room Report: Written (or verbal) report from referring surgeon (if applicable)
Team Work and Communication: Patient and family, physician and surgeon, and therapist
Epidemiology and Fracture Distribution
Second only to forearm fractures in incidence, hand fractures account for up to 20% of fractures in adults and children, with an annual incidence of 36/10,000 people. Hand fractures in both genders occur most commonly in early adolescence, just after the period of most rapid bone growth. Across the lifespan, males have twice the risk of sustaining a hand fracture, with most of this risk occurring between the ages of 15 and 40, the most active and productive working years. As with other “fragility” fractures, women older than 65 are at higher risk (1.5 : 1) for sustaining hand fractures than men. ,
Phalangeal fractures (distal, middle, and proximal) account for more than 50% of hand fractures. However, metacarpals (MCs) are the most common bones fractured, accounting for 35% to 45% of hand fractures, followed by 20% to 25% in the distal phalanx, with the middle and proximal phalanges each accounting for about 15%. Fractures within the fifth (little) ray make up about 40% of hand fractures, with the first (thumb) and fourth (ring) rays each accounting for about 15% to 20%. Extra-articular hand fractures account for 75% to 85% of hand fractures. Work-related hand fractures account for 14% of all hand fractures, with distal phalangeal fractures accounting for up to 60% of extra-articular fractures in a working population, as the fingertip is the most exposed and vulnerable to traumatic occupational injury. In the general population, MC fracture is the most common extra-articular hand fracture.
Medical and Surgical Management
Most patients present with simple, closed, extra-articular hand fractures that are managed nonsurgically with closed reduction, followed in some instances by percutaneous transfixing or intramedullary Kirshner wire (K-wire) fixation to help maintain fracture alignment during initial healing. The advantage of closed reduction, with or without percutaneous pin fixation, is that additional surgical trauma can be avoided. It is generally recommended that closed, extra-articular hand fractures be “immobilized” in a cast or a rigid thermoplastic orthosis for at least 3 to 4 weeks for additional external protection of the healing fracture. Commonly, the cast or orthosis immobilizes the regional hand and wrist joints in the position of function (10–15 degrees of wrist extension, 70 degrees of metacarpophalangeal [MCP] joint flexion, full interphalangeal [IP] joint extension, thumb palmar abduction with web space maintenance), with the flexion creases of noninvolved joints remaining clear for movement. ,
Although some extra-articular hand fractures can be reduced in a closed manner, others may remain structurally fragile or significantly malaligned following attempts at closed reduction. In addition, some hand fractures manifest as more complex clinical injuries, involving significant bone loss or comminution, articular disruption, or open injury in conjunction with other regional tendon, nerve, vascular, and skin tissue injuries that also require treatment. In these circumstances, it is usually recommended that an open surgical or direct fracture reduction be done, supplemented by some form of more stable or rigid internal or external fixation to facilitate direct fracture healing and early motion.
Open reduction and rigid fracture fixation can be technically difficult in the small, contoured hand bones and often require extensive regional soft tissue and periosteal disruption, creating a more clinically complex injury with increased risk for scarring, stiffness, and the need for secondary surgical interventions. , Therefore, it is not uncommon for surgeons to opt for less invasive surgical approaches for fracture reduction or less rigid or more flexible forms of fracture fixation that help maintain fracture alignment. These approaches, however, do not necessarily provide significant additional structural strength or stability to the healing fracture. In these instances, it is generally recommended that the regional hand and wrist joints be immobilized for up to 4 weeks to protect the healing fracture.
Micromotion and Early Fracture Healing
Animal studies have shown that limited or controlled cyclic (usually compressive) microstrain or micromotion introduced during the initial days of healing clearly influences the initial genetic and molecular expression in the callus. , This, in turn, affects initial cellular proliferation and differentiation, all of which ultimately influence the morphologic changes and biomechanical strength of the fracture throughout the early stages of healing, leading to improvements in both quality and rate of fracture healing. However, these same studies also show that too much micromotion of the fracture negatively influences the quality and rate of early fracture healing. Until recently, it was unclear if early, controlled passive motion of regional joints surrounding a potentially unstable fracture in a non-weight-bearing limb would have a positive or negative effect on quality and rate of early fracture healing. In a study of closed, extra-articular third MC fractures in non-weight-bearing limbs in a rabbit, Feehan and colleagues compared fractures treated with immobilization to those treated with a controlled passive motion protocol combined with gentle local pinch fracture stabilization initiated on the fifth day. These authors found statistically and clinically significant improvements (>25% better) in the biomechanical properties (strength and stiffness) and fracture alignment of the healing fracture at 28 days after fracture, providing support for the concept of early controlled and protected motion in the management of fragile extra-articular hand fractures in humans.
Early Motion: Changing Trends and Clinical Evidence
Not all extra-articular hand fractures are immobilized during the early healing phases, as some are considered strong or stable enough to withstand active regional joint motion; these more stable fractures can be categorized into two clinical scenarios. The first is the fracture that has been managed with a more rigid fixation. This is based on the original principle underlying the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) fracture fixation philosophy from the 1950s to 1960s. This concept considers that rigid fixation not only provides a “no-motion” healing environment that facilitates direct internal fracture healing and remodeling without formation of an external callus, but also a mechanical construct of sufficient strength to allow early functional active motion of surrounding joints.
In theory, the concept of rigid fracture fixation combined with early motion sounds ideal. However, the actual functional outcomes from case series studies following rigid (usually plate or screw or plate and screw) fixation in the hand have been less than ideal. This is likely due in part to the intimate and complex regional soft tissue anatomy in the hand, with multilevel, interstitial motion planes that do not tolerate additional restrictive scarring secondary to extensive surgical dissection. However, this is conjecture because clinical evidence to support or refute the use of more rigid fixation alternatives in extra-articular hand fracture management is lacking. Clearly the efficacy and effectiveness of rigid fracture fixation alternatives in extra-articular hand fracture management are areas that need further investigation.
The second scenario for early motion is based on the concept of functional fracture bracing. Generally, this type of bracing is recommended for simple, closed, minimally displaced extra-articular long bone fractures. , Sarmiento and Latta have been strong advocates for functional fracture bracing of long bones for more than 30 years, and Colditz provides an excellent overview of the history, theory, and role of functional fracture bracing in the management of closed stable upper extremity fractures, including MC and proximal phalanx fractures (see Chapter 127 ). Latta and coworkers state that fracture bracing is a philosophy rather than merely the use of orthotic devices, predicated on the belief that immobilization of the joints above and below the fracture is not necessary for secondary fracture healing.
The intent of the fracture brace is not to immobilize the fracture fragment, but to provide sufficient fracture alignment and stability when regional joint motion occurs. The functional fracture brace is designed to provide circumferential regional support of the long bone; the brace is adjustable for variations in swelling or girth of the surrounding soft tissues, with joints both proximal and distal to the fracture free to move through an unrestricted arc of active motion. From an evidence-based practice perspective, there is support from several independently conducted, limited-quality, randomized clinical trials showing consistent potential for improved rates of recovery of mobility, strength, and return to work with no significant risks of harm in simple, closed extra-articular finger MC fractures treated with various forms of “flexible” or more “rigid” forms of external regional fracture bracing and early regional joint motion compared with metacarpal fractures treated with regional immobilization.
During the last decade, a philosophical shift has taken place in the principles of long bone fracture fixation in humans. This shift is moving away from the original AO/ASIF concept of direct (open) anatomic reduction and rigid compressive fracture fixation followed by immediate functional reactivation (absolute or high-stability fixation), to indirect (closed or limited open), near-anatomic reduction combined with minimally invasive, limited contact, flexible fixation methods (relative or low-stability fixation), followed by early protected or controlled mobilization of the affected limb. , This newer concept, known as biologic, or flexible long bone, fixation, was described by Perren as finding a balance between maintaining the biological integrity of the healing fracture and providing a stable mechanical environment that allows for fracture healing and early controlled functional motion rather than immobilization.
In theory, functional fracture bracing is consistent with the concept of biological or flexible fixation, in which a functional fracture brace is defined also as a noninvasive, external, indirect form of flexible fracture fixation. As is true of many of the more commonly used less or minimally invasive techniques, flexible hand fracture fixation alternatives provide some additional fracture alignment and limited structural stability but not necessarily a rigid or no-motion environment for fracture healing. A number of case series studies have reported results for early active motion, combined with variations of fixation that could be defined as biological or flexible fixation options, including K-wire, cerclage wire, and semirigid external fracture fixation for management of extra-articular MC and phalangeal fractures. Good outcomes with few complications were reported in these series. Only one randomized clinical trial compared rigid lag screw fixation with more flexible percutaneous wire fixation. This trial noted no long-term differences in pain, strength, or mobility in oblique and spiral proximal phalangeal fractures for which active motion was initiated 1 week after fracture. Thus, it is difficult to compare the relative efficacy (risk or benefit) of rigid fixation plus early motion with that for flexible fixation plus early motion in the management of extra-articular hand fractures.
As outlined in the literature, the primary concerns with motion surrounding these more flexible K-wires and external fixators is the increased risk for pin track infections and pin migration or loosening associated with regional soft tissue motion around the pins. As well, the motion options that might be available with these types of fixation depend on what soft tissues and joints are skewered with these devices, because such skewering certainly limits the amount of possible soft tissue excursion or joint motion. If the fixation crosses over or through a joint, or through or across a muscle or the extensor apparatus, motion of these joints or full excursion of the muscle or extensor mechanism are not an option until the fixator is removed. Given the concern about increased risk for pin-related complications, it is important to stress that early motion around fractures managed with more flexible forms of pin or wire fixation should be introduced gradually, in a controlled fashion, during the initial stages of fracture healing.
Outcomes and Complications
The most common complications after hand fracture are not delayed union or nonunion or other fracture healing complications (e.g., infection), but rather reduced tendon gliding and tethering, resulting in secondary joint lag, stiffness or contracture, and decreased muscle function (strength, endurance, flexibility, coordination) associated with immobilization. Single, nondisplaced, closed hand fractures treated with no or closed reduction, no fixation, and limited immobilization are associated with minimal long-term morbidity. In contrast, clinical factors associated with increased risk of secondary fracture complications requiring additional or prolonged treatment include multiple fractures, bone loss, other associated regional soft tissue injury, proximal phalangeal fracture, surgical intervention, plate fixation, and immobilization exceeding 4 weeks.
Fortunately, most people with uncomplicated, extra-articular hand fractures regain normal or near-normal regional tissue (joint, tendon, muscle, neurovascular) function and the ability to return to normal participation in daily activities without limitation within 12 weeks after fracture. However, as with other fragile, healing soft tissue injuries in the hand, it is better to try to prevent or reduce postfracture regional tissue dysfunction and facilitate a person’s return to normal daily functioning as soon as possible during the recovery through early thoughtful and controlled therapeutic interventions.
Rehabilitation: General Principles
Defining Relative Stability or Structural Strength
Traditionally, initiation and progression of rehabilitation and functional reactivation of individuals following extra-articular hand fractures have been based on the concept of clinical stability—the point in time when the fracture is considered structurally strong enough to withstand nonresisted, active motion without fracture displacement. In many instances during the initial healing phases, extra-articular hand fractures are considered to be clinically unstable. Early postfracture rehabilitation is often limited to providing an immobilization orthosis and some additional supportive education and advice, with active motion and graduated functional reactivation initiated only after a period of immobilization when regional tissue complications are already established.
The more traditional concept defines the clinically stable fracture as one that can tolerate active motion; a clinically unstable fracture requires immobilization. This chapter presents an alternative view of rehabilitation progression, defining a fracture’s current structural strength as falling somewhere along a continuum of relative stability throughout recovery ( Fig. 31-1 ). This alternative view leads to a number of graduated-motion, external protection, and functional reactivation rehabilitation options based on the current structural strength or relative stability of a fracture in any individual patient at any given point in time during healing and recovery. Following the same principles used when designing, implementing, and progressing through an individualized rehabilitation plan after any fragile healing soft tissue injury (e.g., a tendon, ligament, or nerve injury), therapy should begin within a few days of the injury. Motion is limited or controlled and protected, with functional reactivation as the goal. The degree of protection is progressively decreased, and the types of physiologic loads and functional activities are increased over the next few weeks until full functional recovery has occurred, usually about 3 months after injury.
Defining the current structural strength or relative stability of a healing fracture at any point in time depends on a number of clinical factors as well as the individual’s functional demands and priorities. This involves the same clinical decision-making process as for any other healing, fragile, soft tissue hand injury. In all cases, the structural strength of any healing tissue is relative to the type of stresses or loads the tissues must withstand. As is also true for such tissues, there are no recipes or rules regarding the best type or timing for specific rehabilitation interventions. Each fracture is unique, and the rehabilitation plan must be tailored to each patient’s clinical presentation, specific personal needs and priorities, and daily functional demands. Understanding these unique factors and the specific clinical fracture presentation is critical to developing an efficient and effective rehabilitation plan focused on maximizing the quality and rate of functional recovery.
These factors are detailed in the following discussion.
Which Bone and Where in the Bone?
The fracture location and surrounding soft tissue anatomy define the regional static and dynamic forces that may compromise skeletal alignment. Potential deforming forces acting on a fracture in the neck of a fifth finger MC are quite different from those acting on a fracture in the base of a first MC or the shaft of a second proximal phalange. The clinician needs to understand the nature of these forces in order to plan the appropriate resting joint posture. The correct posture helps neutralize these forces and mitigates or counterbalances them when motion is introduced around a fracture ( Fig. 31-2 ). Understanding the regional anatomy offers insights into what other regional soft tissues may have been injured or compromised functionally due to the initial injury and what secondary surgery or fixation (plus subsequent immobilization) may be needed. As mentioned earlier, the most common complications after a hand fracture are secondary soft tissue complications in the regional joints, tendons, and muscles, not complications associated with fracture healing. Understanding what regional soft tissue complications are likely to occur is the first step in planning a rehabilitation program to prevent them.
Number and Nature of Fracture Line(s)
The pattern of bone structural failure helps define how much the fracture has undermined the inherent structural strength of the bone. Intrinsically, the number of fracture lines and their orientation within the bone determine what types of forces are likely to displace the fracture fragments and in which direction. An oblique or spiral fracture in the midshaft of an MC compared with a transverse fracture in the same location is displaced by different types of (compression, traction, bending, rotation) and directions of (axial, anteroposterior [AP], radioulnar [RU]) forces acting on the bone. Oblique and spiral fractures are displaced more easily with axial compression and rotation forces than are transverse fractures, which are more susceptible to AP and RU forces. The nature and number of fracture lines also characterize the type or pattern of fracture fixation that can be used to help maintain and stabilize fracture alignment during healing.
Initial Fracture Displacement and Alignment
The degree of displacement (amount of associated periosteal disruption) and direction or pattern of actual displacement of the bone fragments at the time of injury also determine the inherent structural damage caused by the fracture; the more periosteal disruption and internal structural bony collapse or failure (comminution) at the time of injury, the greater the loss of intrinsic structural strength even after reduction. In addition, the degree and direction of initial bone fracture displacement define the type and direction of forces required to reduce or realign the fracture fragments. Fractures are generally reduced by introducing forces in a pattern opposite to the original pattern of bone failure or injury and are also generally more tolerant of forces and loads associated with physiologic joint motions distal to the fracture introduced opposite to the pattern of bone failure. If a bone failed from a compression/hyperextension injury, then it is reduced with traction and volar displacement and flexion forces acting on the distal fragment. This same fracture is also likely to be more tolerant of joint motions distal to the fracture moving into flexion rather than end-range extension.
Type of Reduction and Fixation
The type of reduction (closed, limited open/minimally invasive, or open) and the kind, pattern, and location of any additional fixation (none, wire, screw or plate, or both) influence the nature of underlying healing (direct or indirect). Additionally, the type of reduction and fixation defines how bone vascularity and regional soft tissues may have been disrupted and may continue to be affected due to ongoing metal impingement or encroachment. The type of fixation also establishes how much and what types of additional structural strength or stability might be expected from the fixation mechanical construct (minimal, flexible, or low-stability fixation vs. absolute, rigid, or high-stability fixation).
Postreduction and Fixation Alignment
Although the ultimate goal of fracture reduction and fixation is to achieve perfect anatomic alignment, this is often not possible, especially if the fracture has been managed with minimal or closed reduction and minimal or more flexible fracture fixation. Often, the quest for perfect alignment and stability (the perfect radiograph) requires more extensive surgical interventions and greater amounts of residual metal left in the bone or hand, both of which have potential negative effects on the underlying healing and the patient’s functional recovery.
Fortunately, the hand tissues and the person affected have the capacity to compensate and recover functionality, even with extra-articular fractures that heal with a degree of malunion. However, there are limits to the degree and type of malunion that are tolerated or compensated for. What is tolerable varies markedly based on the bone affected, the site of the malunion, and the patient’s needs and priorities for cosmetic and functional recovery. In general, the hand tissues and the patient are better able to compensate for and tolerate volar or dorsal angulation deformities than lateral angulation or rotational deformities that cause the fingertips to move away from the thumb during pinching and gripping activities.
Although the potential risk–benefit ratio of various surgical options is a decision made between the surgeon and patient, therapists need to understand the potential functional implications of different patterns of malunion. This understanding is important not only to ensure that planned therapeutic interventions do not increase the potential for worsening a malunion, especially in situations where the fracture has minimal or no additional fixation, but also to plan specific orthosis use or exercises that will help reduce or prevent complications associated with malunion, in particular any functional bone foreshortening and subsequent loss of active end-range joint motion (or joint lag) in joints distal to the fracture.
Nature of Additional Soft Tissue Injury
The degree of associated soft tissue injury, both from the injury and from any surgical trauma, also needs to be identified as it determines the other regional tissues to be included in the rehabilitation plan. The greater the complexity of associated soft tissue injury, the more complex the rehabilitation plan and the greater the need to ensure that therapy begins early to try to prevent the secondary complications associated with immobilization. Frequently, in the case of multiple tissue trauma injuries, surgeons opt for more extensive surgical interventions and more rigid fracture fixation options in an effort to facilitate earlier rehabilitation. Even when there are no apparent direct soft tissue injuries (such as a tendon or nerve laceration), therapists still need to understand the specific details of how the fracture reduction and fixation were achieved, that is, the technical details of what soft tissues were dissected, retracted, impaled, clamped, and sutured or not sutured; how difficult the reduction and fixation were to achieve; and how confident the surgeon is with the fixation.
It is important to remember that even in conservatively managed, closed-hand fractures, the fracture is just the most obvious injury because it can be seen on the radiograph. Almost all hand fractures are multitissue traumatic injuries and include soft tissue trauma, even if not externally evident. Closed crushing, hitting, torsion-type forces transmitted through the finger or hand with enough force to create underlying bone failure likely cause similar regional neurovascular, muscle, tendon, tendon sheath, or joint capsule–ligament crush, contusion, or tearing-type injuries.
Time Since Fracture or Surgery
The time since fracture or surgery sets the stage for fracture healing, whether the healing is through direct or indirect mechanisms. In general, the longer the time from fracture or surgery, the more structural strength is provided by the underlying bone healing or mineralization process. The majority of extra-articular hand fractures heal through indirect or secondary fracture callus healing, passing through the initial inflammatory phase in the first few days, then through the proliferative fibrocartilage, or soft callus, stage, followed by peripheral bony union or mineralization or hard callus, and then into a final internal bony bridging or mineralization phase. As this progressive mineralization of the fracture callus increases, relative structural strength (stiffness) is regained at the fracture site; this progressive increase in stiffness associated with bone healing or mineralization tends to define the phases or types of rehabilitation interventions and functional reactivation that can occur following a fracture (see Fig. 31-1 and Table 31-1 ).
|Relative Stability: (Structural Strength)||Approximate Timeframes||Acronym||Motion (Joint(s)/Tendon)||External Protection (Fracture)||Reactivation Limitations (Function)|
|Fragile ↓||∼0–3 days||No joint motion: immobilization||Immobilization orthosis: >2 regional joints (worn at all times)|
|Limited Stability ↓||∼3 days–3 weeks||Serial orthosis reduction/modified fracture brace: 1 joint distal + 1 proximal to fracture (off for hand hygiene)||Light pain-free functional activities (with modified fracture brace)|
|Clinical Stability ↓||∼3–6 weeks||Full-arc isolated joint motion: active + passive||Fracture brace: no joints (off at rest/night + light activities)||Moderate pain-free functional activities (with fracture brace)|
|∼6–9 weeks||Full-arc composite joint motion: active + passive (end-range stretching + orthosis)||Limited fracture brace: no joints (on for selected heavier use)||Heavy pain-free functional activities (with fracture brace)|
|∼9–12 weeks||Resisted, full-arc composite joint motion: resisted active (strengthening)||Limited fracture brace: no joints (on for high-risk use)||High-risk (sports, recreation, work) pain-free functional activities (with fracture brace)|
|Functional Stability||>12 weeks||Unrestricted joint motion||No protection||No limitations|
For fractures that have been managed with more rigid fixation, it is important to remember that these forms of fixation do not provide the same relative structural strength as normal bone, and so are not functionally stable. Rather, they provide the relative structural strength equivalent to a clinically stable fracture or a fracture that is able to tolerate unrestricted active motion of the joints adjacent to the fracture without displacement or additional protection during the initial 3 to 4 weeks after fracture. These fractures still need to be protected during functional use, especially during the first 3 to 4 weeks, and they should not be subjected to progressive resisted motion, composite passive stretching, or unprotected moderate to heavier functional use until there is evidence of internal mineralization across the fracture. In terms of timelines, internal mineralization of the fracture following rigid fixation usually occurs around the same time that internal mineralization begins in fractures healing through indirect or secondary fracture callus healing—sometime around 6 weeks after fracture. ,
Normal Daily Functional Demands and Patient Priorities
Understanding the patient’s normal daily functional demands and priorities is crucial to determining the level of protection needed for the fracture during functional use, as well as for defining the priorities and timelines for functional reactivation around the healing fracture. In most instances, a planned and graduated return to normal functional activities, including work, sport, leisure, and personal care activities, can be achieved through the thoughtful design and use of serially reduced or modified external fracture orthoses or braces, as well as a targeted functional reactivation plan consistent with the person’s needs and priorities. The advantage of early, protected functional reactivation throughout fracture healing is that the affected hand is less likely to develop losses of hand pinch and grip strength and endurance associated with early postfracture immobilization and prolonged functional disuse.
Gaining This Understanding
The essential components for gaining an understanding of a fracture’s relative stability are:
A complete and detailed report from the referring physician or surgeon
Access to pre- and postfracture reduction and fixation imaging
An operating room report (if applicable) or direct communication with the referring surgeon regarding details of the surgery
Team work and communication among therapist, physician and surgeon, and patient
Without these essential components of information and support, therapists are essentially treating hand fracture patients “in the dark,” with limited ability to maximize functional recovery. Fortunately, most hand therapists have established close TEAM ( t ogether e veryone a ccomplishes m ore) (see Chapter 29 ) working relationships with referring physicians and surgeons who are used to providing detailed information and referrals to therapists for other types of fragile healing hand injuries. Additionally, many therapists have improved access to imaging and surgical reports as most are now available in digital form and easily transferred and viewed in the clinic on any computer. As with other acute hand injuries, it is the therapist’s responsibility to understand the details of the injury and surgery before beginning intervention and to consult with the physician or surgeon for further details if this information is not available at the time of referral. In addition, therapists and surgeons typically work together to ensure that the patient is the central team member, ensuring that he or she understands the details of the hand fracture and the goals and timelines for recovery, with the therapist and surgeon focusing on monitoring, supporting, and encouraging the patient to achieve the best possible outcome.
Phases of Rehabilitation: Based on Relative Stability
The phases of rehabilitation following an extra-articular hand fracture are essentially the same as those after a healing tendon or nerve repair, beginning with a few days of rest and recovery during the inflammatory stages of healing following the injury, progressing over the next 3 to 4 weeks to limited or controlled motion with a light, functional reactivation program introduced in conjunction with the external protection or support needed. In the weeks that follow, a progressively graduated program of composite active motion, followed by passive stretching, resisted exercise, and functional reactivation, is introduced in conjunction with progressively decreasing or reduced external protection or support for the healing fracture.
Postfracture rehabilitation can be divided into six phases, corresponding to the progress of perceived structural strength or relative stability of the healing fracture (see Fig. 31-1 and Table 31-1 ). However, the initiation and progression or modification of therapy following any hand fracture varies and must be based on an assessment of the fracture’s relative stability at each point in time. These phases of rehabilitation are general guidelines that need to be tailored to each patient.
Phase 1: Fragile Fractures—Rest, Ice, Compression, Elevation (RICE)
During the first 3 to 5 days after injury, an initial hematoma and inflammatory response to the traumatic fracture are seen. During this period, there is no biological or functional advantage to using the hand except for very light and essential self-care. Other than potentially contaminated, open injuries in need of further wound care and monitoring, hand fracture injuries are best left to rest and recover during the first 3 to 5 days after injury. Light, compressive, immobilization dressings or orthoses and hand elevation are effective strategies for minimizing postfracture edema and pain during these initial days. Around 3 to 5 days after fracture, the symptoms of aching pain at rest, at night, and with dependency begin to subside. These are general indications that the degree of fracture immobilization or support can be serially reduced or modified and some early controlled and protected motion and light protected functional reactivation can begin (see Table 31-1 ).
Phase 2: Limited Stability—Controlled, Protected, Reactivation (CPR)
Around the third to the fifth postinjury day, most fractures have some limited stability and can tolerate controlled joint motion, as well as light functional use, if introduced in conjunction with appropriate support and a protective orthosis. Most fractures are not yet strong enough to withstand unrestricted active joint motion or functional use without this additional protection and are often treated with ongoing immobilization. Fortunately, as with other fragile healing soft tissue injuries, many less forceful controlled-motion options can be considered at this time. A number of modified fracture brace designs can provide protection and support during functional use. These modified braces also stabilize or immobilize at least one joint proximal and distal to the fracture at rest and during functional use, while providing the opportunity to introduce controlled motion in the joints under controlled circumstances (see Table 31-1 ).
Phase 3: Clinical Stability—Active, Protected, Reactivation (APR)
After 3 to 4 weeks in most fractures with initial limited stability, and within 3 to 5 days in fractures managed with more rigid forms of plate or screw fixation, enough structural strength or clinical stability is usually achieved to withstand unrestricted, full-arc, regional joint motions. However, the fracture has not yet gained enough strength or stability to withstand composite, end-range, passive-stretching, resisted motion for moderate functional activities without ongoing external support or protection. At this point, functional use of the hand for moderate, pain-free activities is facilitated if the immobilization orthosis or modified fracture brace used during the early phases of rehabilitation is serially reduced to a more traditional, functional fracture brace design so that it provides circumferential support around the fracture but does not include either of the joints proximal or distal to the fracture (see Table 31-1 ).
Phase 4: Graduated, Limited-Protected, Reactivation (GLR)
Around 6 weeks after injury, most extra-articular hand fractures have developed enough structural strength to withstand end-range, composite, active motion and passive end-range stretching exercises or orthosis use, progressive-resisted (light strengthening) exercises, and moderate functional activities without the need for additional fracture support or protection. However, the external support or protection (functional fracture brace) should still be applied when the person uses the hand for heavier strengthening or functional activities (see Table 31-1 ).
Phase 5: Resisted, Limited-Protected, Reactivation (RLR)
About 9 weeks after injury, most extra-articular hand fractures are strong enough to withstand moderate levels of functional demands for occupational and sports-related activities and heavier resisted therapeutic exercises without any additional protection or support. However, fractures still need to be protected with external support or functional fracture bracing during higher-risk, high-impact activities until at least 3 months after fracture (see Table 31-1 ).
Phase 6: Unrestricted Reactivation (UR)
Because no residual hand tissue impairment or dysfunction usually remains 3 months after fracture, the individual should be able to resume normal functional activities without the need for additional support or protection. This is not always the case, however, and the focus at this point is to continue to maximize the recovery of any regional tissue, joint, tendon, and muscle impairment through continued exercises and orthosis use as required. If the patient has yet to return to a typical level of participation in occupational, sports, or other functional activities by 3 months after fracture, further attention should be given to defining specific barriers or limitations to this return and what further modifications or plans are needed to facilitate return to the previous functional level (see Table 31-1 ).
Therapeutic Options: Motion, External Protection, and Functional Reactivation
Figure 31-3 provides an overview of a number of motion, external protection, and functional reactivation alternatives and progressions that therapists might consider following when treating an extra-articular hand fracture. Although these clinical options may appear complex, they are no different from similar clinical options for other fragile, healing hand injuries.
Traditionally, motion of joints surrounding an extra-articular hand fracture is delayed, occurring after removal of an immobilization cast or orthosis, or earlier when a fracture has been managed with more rigid fixation or when it is considered to be clinically stable. In these instances, the motion usually starts with active, full-arc, composite motion of the affected digit or hand. However, a number of motion parameters can be controlled or limited and introduced earlier, when a fracture has more limited relative stability or progressed to more forceful motion options when a fracture has greater relative stability.
The motion parameters that can be limited or controlled include (see Fig. 31-3 ):
Arc of motion (limited or full)
Type of motion (passive, active-assisted, unresisted active, passive end-range, or resisted active)
Direction of motion (flexion or extension, or both)
Number of joints moving (isolated or composite motion)
Frequency of motion (how many, how often)
Conditions of motion (with local fracture stabilization, under supervision, in protective orthosis or unlimited)
How and when to progress motion following a hand fracture depend on the fracture tolerance and how well the patient achieves the motion goals introduced to date. There are no specific timelines or rules for progression, other than achieving pain-free motion based on the relative stability of the underlying fracture. If a patient can successfully and consistently achieve a pain-free, limited-arc, passive, isolated joint motion, then progression can be considered. If, however, such motion is not possible, it is time to revisit and modify the motion goals to a less strenuous or forceful exercise regimen that can be tolerated. If the fracture tolerates this goal and the patient can successfully and consistently achieve a pain-free full arc of unresisted active motion of the joints distal to the fracture, then it is time to consider progressing to composite full-arc or light-resisted active or gentle end-range passive stretching exercises, with or without additional local fracture stabilization or external fracture protection. Alternatively, if this same patient can achieve full, pain-free, composite active flexion of the joints adjacent to the fracture, but cannot consistently maintain full active extension of these joints, then daytime extension blocking orthoses or exercises and nighttime full-extension resting orthosis use should be continued.
External Protection Options
During the initial 3 to 4 weeks after fracture, hand fractures are traditionally managed with some form of rigid external cast, orthosis, or brace within which the regional joints in the affected finger, hand, wrist, and forearm are included, effectively immobilizing all joints within the external support. Although these supports provide adequate protection of the fracture during initial healing, they are not function-friendly, nor do they allow for safe introduction of limited or controlled motion. Secondly, these bulky external supports are often removed completely at 3 to 4 weeks to enable introduction of active motion and light functional use. However, at this point, the underlying fracture is still relatively weak, needing protection from other than light functional use, which means that the patient needs to continue to limit participation in many normal daily functional activities.
The external protection parameters that can be modified or adapted throughout recovery are (see Fig. 31-3 ):
Material (rigid, semirigid, soft or flexible)
Number of joint(s) included at rest (immobilization orthosis [>2 joints]; modified fracture brace [1 joint ± fracture]; functional fracture brace [no joints, circumferential support only]);
Joint(s) posture at rest (flexion, extension)
Other design considerations (volar- or dorsal-based; pin and wound access; strapping options for potential for motion, or additional local stabilization)
Duration of wear (all times; selected or limited)
As with controlled-motion options, there are no rules or best orthosis designs for any given extra-articular hand fracture. Postfracture orthoses or braces should in most cases be custom-designed and molded to suit the individual patient and fracture. The art of designing and fabricating individualized orthoses or modified fracture braces involves finding a balance between ensuring that the design and material provide adequate support and protection for the healing fracture during functional use, while minimizing the number of joints included in the orthosis or brace at rest, and facilitating the introduction of early and controlled-motion alternatives without the need for orthosis removal. In most cases no one orthosis or brace design is adequate throughout a person’s recovery. However, in many cases most custom-designed orthoses can be designed to be serially reduced or modified easily as the relative strength of the fracture increases throughout recovery. Some examples of modified functional fracture brace designs and serial reduction options for different extra-articular hand fractures are presented later in this chapter.
Functional Reactivation Options:
The functional reactivation parameters that can be integrated into a rehabilitation plan are based on the patient’s daily functional demands, needs, and priorities and should be identified early in recovery, along with establishing clear goals. Again, the specific functional demands and protection needed throughout recovery differ for any two individuals presenting with very similar fractures. Functional reactivation for a single, male, competitive college football player wanting to return to his sport is different from that for an elderly retired widow who lives independently and walks with a cane. Both should be able to return to some planned and graduated leisure, occupation, or sporting activities with appropriately designed functional fracture support or protection soon after the fracture. Over the weeks immediately following the fracture, both patients should also have an individualized, planned, and graduated increase in the type, intensity, and duration of activities with a gradual reduction of the required fracture protection needed during functional use (see Fig. 31-3 ).
Early Mobilization: Fracture-Specific Considerations
Regional Deforming Forces: Intrinsic muscle (see Fig. 31-2 )
Malunion: Apex dorsal angulation with bone foreshortening ± lateral deviation or rotation of the distal fragment (see Fig. 31-2 )
Common Soft Tissue Complications
Extensor tendon adherence to underlying callus = active finger composite extensor lag and limited end-range composite flexion (fist)
Intrinsic muscle contracture = limited end-range IP flexion with MCP extension (tuck)
Dorsal incision scar contracture = limited end-range composite finger flexion (fist)
Early Mobilization Considerations
Orthosis Design : MCP held in at least 70 degrees of flexion at rest with circumferential and three-point fracture (apex dorsal) stabilization of the fracture. Provision for additional dynamic local stabilization at the fracture when moving into MCP extension/abduction combined with IP flexion ( Fig. 31-4 )
Extensor Tendon-Gliding Exercises : Early passive or active stabilized composite finger extension (see Fig. 31-4 )
Intrinsic Muscle Exercises: Early stabilized composite finger extension abduction/adduction progressed to composite IP flexion with MCP extension (finger tuck—intrinsic stretch) (see Fig. 31-4 )
Figure 31-5 shows an example of an orthosis design that could be used for a fifth MP fracture that has limited early stability or has been managed with some form of flexible fixation. The initial volar-based immobilization orthosis can be reduced to free the IP joints or serially reduced to a modified functional fracture brace design including only the MCP and the CMC joints within the orthosis (one joint distal and proximal to the fracture). In addition, the orthosis includes an additional three-point (apex dorsal), counterpressure, semirigid dorsal insert and adjustable strapping to ensure consistent circumferential support of the fracture that accommodates variations in swelling and that is consistent with the concept of circumferential functional fracture bracing.