Indications For Surgical Management
Failure to progress with further nonoperative treatment options; typically 4 months or longer from time of injury or initial surgery
Regain passive motion first, then active motion
High degree of patient motivation required before embarking on surgical release and postoperative therapy
Healing Timelines and Progression of Therapy
If no critical structures require protection, therapy progresses as the skin/soft tissue and degree of patient comfort allow
Failing to identify the primary cause of the particular stiffness before attempting surgical correction
Resist the temptation (and often patient pressure) to “jump in early” with regard to surgical management of stiffness; the best results will come to those who wait (again, typically 4 months and plateau in therapy/orthotic use; if either criterion is not yet met, continue nonoperative treatment if possible)
Timing for Return to Work/Activities of Daily Living
Once skin and soft tissues are healed and the patient is comfortable, activities may be increased as tolerated. We use as a general rule of thumb that once range of motion (ROM) is more than 50% to 75%, we start strengthening and once strength is more than 50% to 75%, we allow the patient to begin resuming normal work/sports activities. Of course individualized plans will be required and may necessitate functional capacity evaluations for specialized work situations.
There is not a more universally agreed-upon challenge among patients and professionals who are brought together by injuries and disorders of the hand than combating stiffness. Loosely identified by loss of motion, the type of stiffness about which we write has many dimensions: discomfort, altered tissue dynamics, potential elements of neurovascular dysfunction, and functional compromise. Short-term motion loss accompanying any form of injury or intervention to the hand is to be anticipated. Swelling, pain inhibition, and the need for protection by initial orthotic use all contribute to posttraumatic stiffness. When the tissue response and functional capabilities do not return after a reasonable time and an assiduous pursuit of an advanced rehabilitation program, then surgical solutions may have a role.
It may be at first counterintuitive to approach a problem that has swelling and fibrosis as basic components by contemplating a surgical solution. There is no avoiding the concept that “surgery is injury,” but a controlled approach to release of contracted or immobile structures can be the last and most logical alternative when nonoperative care has failed to optimize outcome.
It should be remembered that releases of the joints themselves only address passive ROM. The intact function of the extensor and flexor systems is still required to actively range the joints. This means that, after a joint release, if passive motion is regained but active motion is still lacking, then extensor and/or flexor tenolysis or other reconstruction is required to regain active motion. An analogy for patient discussions is that the joints are like the wheels of a car, and the tendons are the engine. Typically we try to get the wheels (joints) able to spin as smoothly as possible first. If the wheels are locked up, no matter how hard you run the engine, they will not spin. Once the wheels are freely mobile, we rely on the engine (tendons) to maintain the advances that are made with animating the joints. If the engine is not working, we will need to “power” it with a separate procedure (tenolysis), which is covered in other chapters. In this chapter, we focus on selected concepts, challenges, and complications related to hand stiffness. A thorough description of the anatomy and biomechanics of the hand is essential to the understanding of the development, presentation, and treatment of stiffness and can be found in Chapter 1 . The key facets of surgical planning, technical elements of operative care, and a balanced approach to rehabilitation are explored. This chapter also serves as an update and expansion of the excellent contributions by our colleague, Dr. Peter Innis, in the last edition of this text.
Preventing the Stiff Hand
Preventing the development of stiffness is part of the ideal management of all injuries to the hand. Unfortunately, despite the best efforts of the surgeon, therapist, and patient, some degree of stiffness after any substantial hand injury is nearly inevitable. Principles of treatment include reduction of edema through elevation of the hand above heart level and the use of compressive dressings as the skin and soft tissues allow; positioning and orthotic use as needed, and institution of ROM as soon as possible.
The early reduction of hand edema is critical in the prevention of stiffness. When there is fluid about and within the metacarpophalangeal joint (MCPJ), the joint assumes a posture of extension because this is the position in which the joint can hold the largest volume of fluid. As the MCPJ assumes its extended posture, the proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) tend toward semiflexion as the extensor tone is decreased and the flexor tone is increased at these joints. If left in these positions for an extended period of time, the surrounding capsuloligamentous structures of the joints will become contracted. This is why the edematous, posttraumatic hand will gravitate toward MCPJ extension and interphalangeal joint (IPJ) flexion contractures if left unchecked.
Elevation of the hand to reduce edema should be at or above the level of the heart, both during the day and when sleeping. A sling may be useful but can also be detrimental when used continuously by restricting the movement of the shoulder and elbow. When a sling is used, it should be cinched high so the hand is at or above heart level and the patient should be instructed to perform ROM exercises for the proximal uninvolved joints when out of the sling to prevent loss of motion.
An orthosis is placed on the hand with the finger MCPJ in flexion, the IPJs in extension, and the thumb in abduction whenever possible. This orthosis position counters the nonfunctional posture described previously.
If fractures or injuries to the bone and joint structures are intrinsically stable or adequately stabilized surgically, then an early postoperative motion program can be instituted. In some cases, the injured part and adjacent joints may need to be immobilized for a period of time to allow healing, but motion of the uninvolved and unimmobilized joints should be started as soon as possible to prevent loss of motion and to help to decrease edema.
General Therapy Considerations
The following chapter covers in detail the therapist’s role in the management of the stiff hand. The following are some general therapy considerations that are important to emphasize relative to surgical management.
It is important to keep in mind functional ROM when setting goals for the significantly stiff hand. A study by Hume and colleagues identified functional ROM of the hand for 11 activities of daily living (ADL) using both standard and electrogoniometric methods. They found functional flexion postures averaged 61 degrees at the MCPJ, 60 degrees at the PIPJ, and 39 degrees at the DIPJ. The amount of flexion for the thumb averaged 21 degrees at the MCPJ and 18 degrees at the IPJ. Patients who are unable to achieve these functional ranges may require built-up handles for ADL utensils and specific vocational tool use.
Evaluation of the stiff hand should include the following: active and passive ROM, edema, pain, sensibility, flexor and extensor tendon gliding and length, and intrinsic muscle function and length. Chapter 6 provides a detailed description of the clinical examination of the hand.
Prolonged edema is one of the most common causes of stiffness in the hand. Simons and colleagues described three different venous pumping systems in the hand and specific exercises to activate each one. In all the subjects, an increase in the velocity of venous return occurred when individual systems were activated. The deep venous system in the palm can be activated with isometric intrinsic muscle contraction by adducting the digits against resistance. The superficial dorsal and superficial palmar systems are activated the most by external compression. The authors showed that these systems also act together and produce the greatest effect during fist formation. The effects during fist formation were found to be potentiated by abducting the digits.
Kinesiotaping is another proposed method of controlling edema when wound healing permits. This helps alleviate pain and is theorized to facilitate lymphatic drainage by microscopically lifting the skin during active motion. Pressure and irritation may be taken off the neural and sensory receptors, which results in decreased pain. Pressure is gradually taken off the lymphatic system, which aids in lymphatic return. Further research is needed to support the use of kinesiotaping for edema control.
Orthoses are frequently used in the management of stiffness of the hand. The following chapter covers in detail the use of orthoses in the management of hand stiffness. In general, the type of orthosis used and the schedule of use is individualized depending on a number of factors such as the phase of healing after injury or surgery and whether the purpose of the orthosis is protective or corrective. Orthoses can be static, dynamic, and static progressive. , Flowers proposed an algorithm to guide therapists in their splint selection based on clinical assessment of tissue compliance using a modified Weeks test. This procedure involves taking a passive ROM measurement of the stiff joint before any exercise or modality, i.e., a “cold reading.” A second reading is taken after treatment including a thermal modality and exercise followed by sustained positioning of the stiff joint at the end of its available motion. The two readings are compared to determine the gain in ROM, which reflects tissue compliance and the severity of stiffness. Orthoses are chosen based on the degree of tissue compliance ( Table 66-1 ).
|PROM Increase (degrees)||Orthotic Technique|
|0–5||Static progressive orthosis|
Colditz , described a casting technique used to help facilitate a more normal pattern of motion as well as increased ROM for use with the significantly stiff hand. The technique, called casting motion to mobilize stiffness, is described in detail in the following chapter.
The Digit Widget is an external fixator-type device used to increase ROM typically for PIP flexion contractures. It is used after an unsuccessful trial of orthosis use or before surgical release for severe flexion contractures to facilitate the surgery. Pins are surgically inserted into the patient’s bone distal to the target joint ( Fig. 66-1 ). The frame is affixed to the pins and strapped to the hand, and rubber bands are applied. These bands exert a constant extension torque on the PIP joint.
Patients should be monitored closely after the application of any type of orthosis for signs of inflammation including erythema, heat, increased pain or edema, decreased active/passive ROM, and decreased sensation. When any of these signs or symptoms are present, the orthosis should be checked for proper fit and pressure distribution. ROM should be reassessed every 2 to 3 days to monitor progress and the effectiveness of the orthosis. Plateaus in ROM gains may indicate the need for a different orthosis design and/or change in exercise program. It is important to frequently review the patient’s home program of orthosis wear and exercise to ensure compliance.
Exercises after surgery for stiffness are selected and begun based on the surgical procedure performed. For example, ROM exercises, both passive and active, are indicated after surgical release of a stiff and contracted joint(s). With tenolysis of adherent and scarred tendons, isolated and differential tendon-gliding exercises must be included as well. It is important to know the preoperative pattern of stiffness and what was achieved at surgery to appropriately set goals for therapy. Exercises are typically begun as soon as possible postoperatively. See Chapters 40 and 68 for therapy after flexor and extensor tenolysis and MCPJ and IPJ capsulectomies.
Outcomes of surgical procedures of the stiff hand can be assessed by using the End Result Committee of the American Society for Surgery of the Hand values for digital functional assessment ( Table 66-2 ).