Protocols

Recent fractures of the scaphoid bone

Phase 1: immobilization

Phase 2: pre-consolidation

Phase 3: consolidation

Rehabilitation

Therapeutic goals: immobilization

Techniques:

Monitoring of the orthosis (stability, comfort, pressure points)

PRICE protocol

Mobilizations of the free joints (shoulder, elbow, fingers, interphalangeal of the thumb)

Risks: trophic disorders, CRPS

Therapeutic goals: progressive load, gain joint amplitude, progressive muscular reinforcement with fingers extended

Techniques:

Massages, manual and instrumental mobilization, fluidotherapy

Relaxing of the scar (if surgery)

Electrostimulation, transcutaneous vibratory stimulations ++, intrinsic muscles, and wrist stabilizers

Exercises for fine prehensions, digital coordination

Risks: stiffness, muscle atrophy

Therapeutic goals: regain total joint amplitude, muscular reinforcement, proprioceptive exercises, and functional goals

Techniques:

Specific intracarpal mobilizations

Muscular reinforcement, exercises for the muscular chains

Proprioception exercises

Exercises for strong prehensions, professional or sports orientation

Risks: stiffness, loss of strength

Orthosis

Immobilizing the wrist, worn all the time

Functional for the wrist during activities

Flexible for restarting work or sports activities

Sprains of the scapholunate ligament
	Phase 1: healing	Phase 2: relative fragility	Phase 3: solidity
Rehabilitation	Therapeutic goals: healing phase, strict immobilization, no load carrying Techniques: Monitoring of the orthosis (comfort, pressure points) PRICE protocol Mobilizations of the free joints (shoulder, elbow), mobilization without resistance of the digital chains (exercises at home) Risks: nonobservance of the immobilization and safety advices	Therapeutic goals: pre-consolidation phase, progressively putting constraints on the scapholunate ligament, stability, fight against muscular atrophy Techniques: Relaxing of the scar and skin (massage) “De-rust” the joints, fluidotherapy Static reinforcement with an open palm (electrostimulation, wrist stabilizers, transcutaneous vibratory stimulations, simple active mobilizations) Risks: no kneading, avoid axial compressions caused by over-soliciting the finger flexors. No analytical exercise for the extensor carpi ulnaris that can damage the scapholunate ligament	Therapeutic goals: regain total joint amplitude, stability ++, and functional goals (work and sports activities) Techniques: Specific intracarpal mobilizations Static instrumental muscular reinforcement Dynamic muscular reinforcement with light weights Proprioception exercises and multidirectional resistances Risks: stiffness or instability of the wrist
Orthosis	Closed antebrachio-palmar orthosis, wrist in 0° of flexo-extension and 5° of ulnar inclination, fingers free	Resting orthosis progressively taken off	Wraparound cuff when restarting activities

Recent fractures of the inferior extremity of the radius
	Immobilization phase	End of the immobilization	Consolidation phase
Rehabilitation	Therapeutic goals: immobilization of the wrist with a cast or a closed orthosis for good healing, maintaining prehension schemas without constraints Techniques: PRICE protocol Mobilization advices for the free joints of the superior limb Vibralgic on the finger pulps, contacts between the palm and the pulps Control of the pressure points of the cast or orthosis and of the pins (if surgery) Risks: maladapted immobilization, CRPS, Volkmann, cutaneous disorders, stiffness if no digital mobilization	Therapeutic goals: fight against trophic disorders and pain, progressively regain joint amplitudes, muscular awakening and maintaining prehension schemas Techniques: Trophic and analgesic massages, analgesic electrotherapy (100 Hz), fluidotherapy, infrasounds, pressotherapy Passive and soft active mobilizations, Kinetec Electroactive exercises for the intrinsic and extrinsic muscles, muscular irradiation techniques then static exercises with light weights, soft occupational therapy Risks: Displacement if the techniques are too agressive and the muscles are too solicited, stiffness and exclusion syndrome if the techniques are too soft and the muscles are not solicited enough	Therapeutic goals: completely regain joint amplitude, muscular strength, and prehensions Techniques: Intensify the techniques from the previous phase Specific intracarpal mobilizations Proprioceptive exercises and feedforward More intensive occupational therapy Risks: same + tendinopathy if work and sports activities are too intense at first
Orthosis	Cast, closed orthosis or opened orthosis	Opened orthosis during the night if pain persists and during “risky” activities	Neoprene orthosis to progressively restart activities if necessary

18.2 Osseous and Capsulo-ligamentous Injuries of the Hand and Thumb

Serious sprains of the internal collateral ligament of the metacarpophalangeal of the thumb (surgery)
	Immobilization phase (A)	Fragility phase (B)	Strength phase (C)
Rehabilitation	Therapeutic goals: immobilization, self-rehabilitation advices Techniques: Monitoring of the orthosis (pressure points) Active self-mobilizations of the interphalangeal, cryotherapy if global inflammation Risks: bad ligament healing, stiffness of the interphalangeal	Therapeutic goals: same and even intensify phase A if necessary (interphalangeal stiffness). Fight against pain and trophic disorders, regain the active amplitudes in the metacarpophalangeal and the interphalangeal joints, reinforcement of the metacarpophalangeal stabilizers, regain coordination and dexterity Techniques: Progressively take off the orthosis Massages, fluidotherapy, transcutaneous vibratory stimulations, depressotherapy, electrotherapy Active exercise to regain the active amplitudes in the metacarpophalangeal and the interphalangeal joints Electrostimulations, static exercise for the internal sesamoid muscles ++ and for the other stabilizers of the metacarpophalangeal joint Manipulations and occupational therapy Risks: same as in phase A + instabilities if the techniques are too intense	Therapeutic goals: intensify the techniques from the 2 previous phases if necessary, regain clamping strength, complete functional recovery Techniques: Specific joint mobilizations and increase the intensities of the electrostimulation Exercise for the intrinsic and extrinsic strength Functional exercise according to the job and leisure activities Risks: same as in phases A and B
Orthosis	Orthosis blocking the metacarpophalangeal of the thumb, interphalangeal is free (worn all the time)	Progressively take off the orthosis	“Alpine” orthosis if necessary to get back to activities

Fractures of the metacarpals and phalanges
	Immobilization phase (A)	Fragility phase (B) Beginning of the rehabilitation if no immobilization (D2)	Strength phase (C)
Rehabilitation	Therapeutic goals: fight against trophic disorders and pain, maintain mobility in the free joints, prevent vicious callus Techniques: Ice (gaseous cryotherapy after the scar is closed or if there is no scar), analgesic transcutaneous vibratory stimulations, analgesic and draining massages, compressive bandages (if possible) Active self-mobilizations of the free joints Learning protection rules when monitoring the orthosis (+ control by the orthotist once a week to control the rotation and the angle of the callus) Risks: vicious callus (especially if there is an orthopedic treatment), stiffness of the free joints	Therapeutic goals: same as in phase A, intensify phase A if necessary (stiffness ++), softly regain joint amplitudes in immobilized/damaged joints, muscular awakening, maintain the body mapping Techniques: Same techniques as in phase A, using more intensive techniques (pressotherapy, cold baths…) Fluidotherapy, depressotherapy and massages against adherences, active electrotherapy, manual mobilizations Soft electrostimulation of the intrinsic muscles Manipulations, occupational therapy Risks: same as in phase A, functional exclusion	Therapeutic goals: intensify the techniques from the 2 previous phases if necessary, regain clamping strength, complete functional recovery Techniques: Specific joint mobilizations, increase the intensity of the electrostimulation, and stretching of the intrinsic muscles (B1) Exercise for the intrinsic and extrinsic strengths, regain the muscular ratios Functional exercises depending on the job and leisure activities Risks: same as in phase B
Orthosis	Orthosis adapted to the type of fracture	Postural orthosis after the end of the trophic disorders and pain	Same as in phase B