INTRODUCTION
A partial or limited carpal fusion is indicated when persisting pain is associated with localized wrist disease, such as scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC). This surgical approach is considered “function preserving,” since restricted arthrodesis of the carpus maintains approximately 50% of wrist motion. Thus, motion is thought to be adequate for the functional performance of most activities of daily living.
Little research has been undertaken to ascertain the functional consequences of partial carpal fusion, although some impairments such as wrist range of motion and grip strength have been consistently documented. Understanding the functional consequences of this surgical procedure provides clinicians with information on the need for and the type of rehabilitation required for optimizing the use of the affected hand after surgery. This means that rehabilitation programs can be designed to remediate frequently occurring issues or deficits in these patients and to educate them on the expected long-term outcome after surgery.
Rehabilitation is defined as the “restoration of an individual or part to normal or near normal function after a disabling disease, injury….” Hand therapists are specialists in providing rehabilitation after wrist and hand injury. They use techniques such as therapeutic exercise, massage, manipulation, hydrotherapy, cold, heat, and electrical stimulation to increase the patient’s ability to perform activities of daily living and work-related tasks. Selection of the most appropriate rehabilitation technique can be daunting for the hand therapist because of the number and diversity of available treatment techniques. Guidance on treatment selection should be based on evidence-based practice (EBP): “the integration of best research evidence with clinical experience and patient values.” This means that decisions regarding the type of treatments used to manage a patient following partial carpal fusion should be based not only on the hand therapist’s clinical experience and the patient’s preference but also on research evidence. Thus, research evidence, that is, information that has been generated by systematic evaluation with the aim of establishing facts, must form part of the rehabilitation decision-making process.
This chapter describes the small body of literature and research evidence that underpins rehabilitation after partial carpal fusion. The content of published rehabilitation protocols is described, and research evidence is presented that supports the remediation of impairments and the treatment of functional difficulties. Outcomes of partial carpal fusion are synthesized, gaps in this evidence are highlighted, and the functional consequences of partial wrist fusion are presented. Based on these limitations, recommendations are made regarding rehabilitation after partial carpal fusion.
REHABILITATION
Research Evidence Underpinning Remediation of Impairments
Little has been published on the content of rehabilitation programs following partial carpal fusion. Only six programs have been found, and all are based on anecdotal or clinical information rather than being underpinned by research evidence ( Table 36-1 ). Table 36-1 illustrates that the type of fixation dictates the period of wrist immobilization. In general, the wrist tends to be immobilized for up to 6 weeks in either a plaster-of-Paris cast or a removable thermoplastic splint. Rehabilitation is commenced during the immobilization period and may consist of mobilization of the fingers and forearm (within constraints of the cast or splint) and edema control measures (e.g., ice, compression, elevation, compression glove). After removal of the plaster cast or splint, the aims of rehabilitation appear to be to increase motion at the wrist within the constraints of the arthrodesis, to strengthen the wrist and hand, and to carry out scar management. These aims can be achieved by mobilization of the digits, wrist, and forearm; strengthening exercises; stretching exercises; edema management; electrotherapy; and splinting techniques. These treatment techniques address impairments (deviations in body structure and body function).
| Author | IMMOBILIZATION PERIOD | After Immobilization | ||
|---|---|---|---|---|
| Length (wk) | Method | Rehabilitation | ||
| Cannon | 10–12 |
| Active and passive ROM to hand, elbow, and shoulder |
|
| 6 (K wires) |
| ||
| 3–4 (screws) | Short-arm splint | Early wrist ROM exercises | ||
| Meads & Prosser | 6 | Cast or removable splint |
|
|
| 6 (K wires) |
| Digit, forearm, and tendon gliding exercises | Rehabilitation only required with longer immobilization (ROM, strength, endurance) |
| 3–4 (screws or spider plate) | Short-arm cast for 3–4 wk | |||
| Walsh & Harper | 6 | Cast or splint | Digit ROM Glove to control swelling | Regain partial wrist motion |
| van Riet & Bain | 4–6 |
| Mobilization | |
Mobilization of Digits, Wrist, and Forearm
The development of implants that increase the early stability of the arthrodesis has allowed early wrist mobilization following partial carpal fusion. Early mobilization rehabilitation programs have consequently been developed for Kirschner (K)-wire and screw/plate fixation (see Table 36-1 ). Early protected mobilization has the potential to decrease pain and edema in acute injuries, and anecdotally similar effects have been observed after partial carpal fusion.
Strengthening Exercises
Short periods of immobilization are necessary to ensure adequate stability of the arthrodesis. However, immobilization also has negative effects, such as muscle atrophy and weakness. Thus, strengthening exercises are indicated to reverse these potentially negative effects. Moreover, patients with longstanding wrist pain, such as those for whom partial carpal fusion is indicated, may have reduced functional capacity, which compounds muscle atrophy and weakness issues. Based on this premise, it appears that wrist and hand strengthening—and perhaps strengthening of the whole upper limb—is indicated following partial carpal fusion, once there is radiographic evidence of carpal fusion. If strengthening is commenced too soon, the implant bears the load. This increases the risk of implant failure and nonunion.
Theories of muscle strengthening suggest that isometric exercise (i.e., a muscle contraction without movement) should be undertaken when there is significant muscle weakness and when stability is required over a joint. Isotonic exercises (when the joint moves through range against constant resistance) are usually undertaken later during rehabilitation to replicate the more dynamic nature of activities of daily living. However, little is known about the strength deficits in partial carpal fusion patients before surgery and how these deficits impact their recovery after surgery. Future research in this area would provide valuable information that could inform partial carpal fusion rehabilitation programs. In addition, there is a need to determine the most appropriate strengthening regimen following fusion.
Stretching Exercises
After partial carpal fusion, stretching techniques are used to address soft tissue tightness or joint stiffness that limits motion of the fingers, wrist, and forearm. Tightness of the longer finger flexors and extensors can be addressed by sustained stretching techniques and dynamic or static progressive splinting. Stretching not only addresses limited motion but also has other benefits, such as improving circulation, preventing excessive scar adhesion, and reducing muscle resistance during motion. Further research is warranted to determine the most effective stretching techniques for patients following partial carpal fusion.
Edema Management Techniques
Villeco and colleagues state that the prevention of edema in the hand is of utmost importance, since edema leads to pain, stiffness, and compromised function. Because interstitial fluid may increase by one third before edema is observable in the hand, routine preventive therapy, such as the use of ice and elevation, is indicated after hand surgery. Compression gloves may be useful in reducing edema, based on research conducted on patients with rheumatoid arthritis. Evidence suggests that the application of ice cools injured soft tissues and therefore reduces edema, and that massage increases lymphatic flow and mobilizes tissue fluid. Basic science research has also established that elevation of the edematous limb decreases hydrostatic pressure and therefore reduces the accumulation of interstitial fluid. Moreover, gentle movements in elevation assist with venous and lymphatic drainage.
Electrotherapy
Electrotherapy may be used to reduce pain and edema after partial carpal fusion. However, equivocal evidence exists regarding the effectiveness of both ultrasound and interferential therapy. Despite this, some evidence supports the use of low-intensity pulsed ultrasound (<0.1 watt/cm ) to accelerate healing in humans after fracture. Given the variable rates of nonunion after partial carpal fusion ( Table 36-2 ), further research investigating the effectiveness of this therapeutic modality after fusion is warranted.
Static Splinting
Static splints are generally used for two purposes:
- 1.
Immobilization of the wrist to allow for arthrodesis. These splints are worn continually during this period, but can be removed for hygiene purposes and for gentle wrist mobilizing exercises (see Table 36-1 ).
- 2.
Protection of the arthrodesis during activities in which large forces are transmitted through the wrist. Intermittent use of splints throughout the day has been recommended when performing heavy, painful, or risky activities, such as during sleep, in crowded situations, and when playing sports.
Custom-made or off-the-shelf volar wrist cockup splints are most frequently prescribed for patients who have had partial carpal fusions. These splints position the wrist in slight extension and allow full movement of the metacarpophalangeal joints, thumb, and fingers. Alternatively, circumferential splints could be used during the immobilization phase because they provide support for both the volar and dorsal aspects of the wrist. The reader is referred to splinting texts, such as those by Mackin and co-authors and Sailer and Salisbury-Milan, which provide detailed information regarding the rationale for splint prescription and manufacture.
Research Evidence Addressing Functional Difficulties
Table 36-1 illustrates that published rehabilitation programs have a tendency not to address the functional ability of patients following partial carpal fusion, However, a direct, linear relationship between functional ability and impairments (e.g., lack of motion and lack of strength and endurance) does not exist, since other factors such as the patient’s personality and the environment influence whether impairments lead to dysfunction (termed activity limitation and participation restriction in the World Health Organization’s disability model). This means that a patient’s functional ability may not be adequately remediated if only the impairments are addressed. Rather, functional ability should to be evaluated directly (either by observing the patient perform activities within his or her environment or by requesting the patient to rate the difficulty experienced while performing activities) and addressed in rehabilitation programs.
One rehabilitation method of addressing the functional consequences of partial carpal fusion is task-orientated training. This approach specifically directs treatment at the activities or the components of activities that are difficult for the patient to perform rather than focusing on the isolated remediation of impairments. Rehabilitation is directed at facilitating motor learning related to the performance of discrete concrete activities by engaging patients with these activities and relevant, associated objects. Because the focus of task-orientated training is on familiar, everyday activities within the rehabilitation setting, there is great potential for carry-over of learned strategies into real-life situations. Moreover, since patients are actively engaged with problem-solving, these new skills may be applied to unpracticed but difficult activities. Although there is emerging evidence that task-orientated training may be effective in the rehabilitation of the upper limb in stroke survivors, this approach to rehabilitation has not been applied to peripheral upper limb injuries or following surgery. However, it has one appeal: task-oriented training focuses on movement strategies that are tailored to each patient and that can be applied across different activities and environments.
OUTCOMES
Current Data
Table 36-2 provides a summary of 13 published longitudinal studies that have documented the outcome of one of the most frequently performed types of partial carpal fusion: a four-corner fusion. Impairments and functional outcomes were evaluated using various research methodologies and different types of outcome measures. In general, patients report little or no wrist pain, approximately 56% of wrist motion, and 64% of grip strength when compared with the contralateral side 1 to 6 years after partial carpal fusion. Although wrist motion appears to be adequate for most activities, most patients in these series regained less wrist motion than predicated, based on the results reported by Gellman and colleagues and Garcia-Elias and colleagues (64% flexion-extension arc following four-corner fusion). In contrast to these impairment outcomes, function was less frequently evaluated. The results reported by Chung, Cohen, Dacho, Sauerbier, Tomaino, and Vance and their associates suggest that mild to moderate dysfunction occurs after partial carpal fusion.
Although it appears that outcomes are currently satisfactory, many unanswered questions remain. It is not known whether the patient’s wrist pain has an impact on the ability to use the hand during daily activities and work-related tasks. Nor is it known whether functional ability could be further increased postoperatively. In addition, there may be specific functional limitations that frequently occur after partial carpal fusion that could be remediated by hand therapy. These issues suggest that further research is required to document the functional consequences of partial carpal fusion and the impact that rehabilitation has on function.
Table 36-2 also illustrates that the method of functional assessment varied among the published studies. Outcome instruments used included visual analogue scales, the Michigan Hand Outcomes Questionnaire, the disabilities of the arm, shoulder and hand (DASH) scores, and the Activity Rating Scale. Moreover, there is potential to use the Patient Rated Wrist Evaluation and the Upper Extremity Functional Index. At present, however, the psychometric properties of these outcome instruments have not been established for patients who have had partial carpal fusion. This means that it is not known whether the items contained within these instruments are relevant for carpal fusion patients and whether they are able to detect meaningful issues in functioning (for both the patients and clinician) after partial carpal fusion.
FUNCTIONAL CONSEQUENCES OF PARTIAL CARPAL FUSION
In response to the limited evidence regarding the functional consequences of partial carpal fusion, a cross-sectional study was undertaken on adults with a unilateral four-corner fusion. The aim of this study was to document difficulties experienced with daily activities, work-related tasks, and recreational activities using the Adelaide Questionnaire in patients who had undergone four-corner wrist fusion surgery. The psychometric properties of the Adelaide Questionnaire were specifically evaluated in patients following fusion to aid in interpretation of the results. Detailed information regarding this study can be found in other publications.
Twenty-five patients took part in the study, and the Adelaide Questionnaire was completed an average of 4.2 years (SD 2.7 years) after fusion. Four-corner wrist fusion was performed by one surgeon, and all patients were provided with the same postsurgical rehabilitation. No patients received treatment for their wrist at the time of this study. Functional consequences of partial carpal fusion were described, using simple statistics from data collected from the Adelaide Questionnaire.
The Adelaide Questionnaire
The Adelaide Questionnaire is a psychometrically sound questionnaire that evaluates difficulty in performing activities from the patient’s perspective and recognizes that outcome is influenced by the patient’s role in society and the extent to which compensatory mechanisms are used. The content of the Adelaide Questionnaire was empirically derived and consists of three sections:
- 1.
The Standardized Section evaluates the patient’s ability to perform 25 daily tasks at two distinct points in time: before the wrist injury or surgery and at present. Patients choose the most appropriate response option that describes the performance of each activity over the last week. Response options include “yes” (I have difficulty performing that activity), “no” (I do not have difficulty performing this activity), “haven’t tried” (I have not attempted to perform this activity over the last week), and “not applicable” (I do not normally perform this activity). “Yes’’ responses can be tallied at both points in time to provide a measure of activity limitation. These scores range from 0 (no activity limitation associated with these activities) to 25 (maximum activity, limitation associated with these activities).
- 2.
In the Individualized Section patients identify activities that are difficult to perform and that are not included in the Standardized Section of the Adelaide Questionnaire. Prior research indicates that the activities nominated in this section tend to be those that are specific to the individual’s role and personal circumstance. Patients are required to nominate five problematic activities and to rate their difficulty and importance according to a 5-point scale (1 = no difficulty/not important, 5 = impossible/essential). Difficulty and importance scores are summed up for each activity and tallied across the five activities. Scores range from 0 (no activity limitation) to 50 (maximum activity limitation associated with the activities nominated). This section also contains additional items regarding compensatory mechanism use associated with the nominated activities.
- 3.
The demographic component collects information about the patient, such as age, gender, dominance of the injury, and work status.
Preliminary psychometric evaluation (face and content validity, test-retest reliability) of the Adelaide Questionnaire has been undertaken on patients with mixed, unilateral musculoskeletal diagnoses. Results were excellent. Although wrist fusion patients were included in these evaluations, the small number of patients with this diagnosis precludes definitive conclusions regarding the psychometric properties of the Adelaide Questionnaire for patients with partial carpal fusion.
Test-Retest Reliability of the Adelaide Questionnaire
Twenty-one patients completed the Adelaide Questionnaire on two occasions, 3 weeks apart ( Table 36-3 ).The test-retest reliability of the Standardized and Individualized Sections of the questionnaire were excellent (intraclass correlation coefficient > 0.95). This means that patients with four-corner wrist fusion can interpret the items of the Adelaide Questionnaire consistently over a 3-week period.
| Demographic Characteristic | All Participants | Participants in Reliability Study |
|---|---|---|
| Number | 25 | 21 |
| Age (yr) | ||
|
|
|
| Gender | ||
|
|
|
| Dominance of injury | ||
|
|
|
| Preoperative diagnosis | ||
|
|
|
| 2 (8%) | 2 (10%) |
| Time since surgery (yr) | ||
| 4.6 (2.9) | 4.2 (2.7) |
| 0.5–9.4 | 0.5-9.3 |
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