Rehabilitation and Splinting
James D. Bedford
All decisions regarding rehabilitation should be customized to the injury and to the patient.
It is important for the hand surgeon to have clear and effective communication with a team of hand therapists and to communicate with each patient the importance of compliance with rehabilitation.
PRINCIPLES OF REHABILITATION
Early goals: reduce edema, manage pain, promote healing, prevent deformity, and maximize functional motion while protecting injured structures
Late goals: allow return to activities of daily living, allow return to work, manage mechanical dysfunction, and manage pain, scar tissue and hypersensitivity
PRINCIPLES OF SPLINTING
Immobilization for protection and pain relief
Following nerve injury: decrease tension on repair
After fracture: reduce risk of displacement or reinjury
Immobilization to allow healing
Maintain alignment of well-reduced fractures
Soft tissue injuries: protect and prevent overuse
Following repair/reconstruction: Immobilization protocols should be tailored to the specific procedure
Tendon repairs should be protected, and early therapy initiated for appropriate patients
Provide passive stretch
Prevent joint contracture
Overcome established contracture
The position of safe immobilization (POSI)
The POSI is designed to place the joints of the hand in positions that reduce the risk of contractures. It is typically referred to as the intrinsic plus position (Figure 62.1).
Improve function by correcting deformity, such as in nerve palsy or tendon dysfunction (e.g. swan neck deformity)
EDEMA CONTROL AND MANAGEMENT
Edema is the pathologic accumulation of extracellular fluid. In the hand, soft tissues may develop edema following injury or surgery, with a variety of effects:
Subcutaneous edema leads to obvious swelling, with greater capacity for swelling on the dorsum of the hand in nonglabrous skin
Edema within tendon sheaths produces increased gliding resistance, which is especially important in the context of tendon repairs.
Edema may cause nerve compression symptoms, including altered sensation in affected digits.
Generalized edema in the hand produces a typical posture of metacarpophalangeal joint (MCPJ) hyperextension, interphalangeal joint (IPJ) flexion, and thumb adduction; this is known as the intrinsic minus position.
The consequences of edema are contrary to the goals of surgery and therapy:
Impaired wound healing and increased susceptibility to infection
Resistance to passive and active joint motion
Risk of fibrosis and permanent joint contracture
The specific consequence of the intrinsic minus position is proximal interphalangeal joint (PIPJ) flexion contracture because of fibrosis of the volar plate in its shortened position and MCPJ extension contracture as a result of fibrosis of the collateral ligaments in their shortened positions.
Active and passive range of motion (ROM) exercises
Retrograde massage and/or compression via bandaging or garments/gloves
Contrast bathing: alternating between warm and iced water baths
Hand surgery centers have their own protocols for the rehabilitation of common injuries. These protocols have coevolved in recent decades with the surgical techniques of repair and reconstruction for hand injuries.
This phenomenon is perhaps most notable in the treatment of flexor tendon injuries. Tendon repairs have evolved to improve strength of repair by increasing number of core strands from two to four or six. This has allowed for the development and use of early active motion protocols. The importance of reducing bulk and gapping at the repair site with low-profile epitendinous sutures has also become more commonly used, allowing better tendon gliding.
Given the improved treatment protocols, rehabilitation regimes that place higher demands on surgeons’ repairs have developed. As combined passive and early active mobilization has overtaken purely passive regimens as the preferred way to rehabilitate flexor tendons, functional outcomes of tendon repairs have continued to improve.
Rehabilitation over a period of weeks to months can be helped by consistency of therapy staff and by clearly written patient instructions. Some centers may also consider telephone or video call “clinics,” especially if their patient catchment area is wide.
The rehabilitation protocols described below summarize typical protocols that may be used, but may vary depending on the center, patient factors, and therapist experience.
The ideal splint material would have the following properties:
A balance between durability (to resist breakage) and malleability/formability (to permit construction)
Resistance to infection
Nontoxic and hypoallergenic
Commonly used splint materials:
Plaster of Paris (calcium sulfate hemihydrate, CaSO4•0.5H2O), commonly used by surgeons fabricating postoperative splints, and occasionally used by hand therapists when removable splints are contraindicated
Resin cast, a formable roll of material commonly used to fabricate cylindrical casts, and which is less brittle and less prone to softening with further exposure to water than plaster of Paris
Thermoplastics, which are formable and conformable when heated in a water bath and rapidly set as they cool to room temperature. Commonly used for fabrication of custom splints, fastened by Velcro, and may integrate springs or elastic to provide dynamic effects
Neoprene and stretchable woven fabrics may be used for positioning where absolute immobilization is not required.
Aluminum with foam backing (AlumaFoam/Zimmer splint) is commonly used to fashion single-digit splints, which are affixed to the affected finger with coban tape, or Elastoplast.
Tape or Velcro buddy straps can be used alone for buddy-strapping of an injured digit to its uninjured neighbor.
Rules common to all protocols:
The surgeon must clearly communicate the instructions for rehabilitation to their therapy team, particularly if there is any deviation from a standard protocol.
Good outcomes are dependent on a mutual understanding between the therapist and the patient of the level of commitment required and on the goals of therapy.
Initiation of therapy
Most therapy protocols will commence 5 to 7 days postoperatively.
Flexor tendon repairs should typically be seen earlier, ideally within 3 days following repair.
Early therapy may allow a reduction in postoperative pain and swelling.
The first visit typically includes a change from postoperative splint to well-fitted therapeutic splint
Extensor Tendon Injuries
Zone I (mallet injuries) and zone II
Manage in distal interphalangeal joint (DIPJ) hyperextension splint (-10°) but avoid skin blanching which can lead to skin necrosis
Can be commercial (eg, Stack splint) or custom (eg, AlumaFoam/Zimmer or thermoplastic)
Fit must be snug; check and adjust as initial swelling subsides.
Splint initially for 6 weeks (surgical repair or bony mallet) or 8 weeks (closed soft tissue); strictly no DIPJ flexion.
Wean (night wear) for further 2 weeks; this protocol may vary depending on center and therapist experience.
Commence gentle active motion at 6-8 weeks.
Graded return to normal activities from 10 to 12 weeks but avoid passive DIPJ flexion until 12-14 weeks
Maintain PIPJ and MCPJ active range throughout.
Zone III (central slip injuries)
Manage initially in digital volar gutter splint.
Surgical repairs for 2 weeks closed tendon injuries for 3 weeks
Allow free DIPJ from week 1 to 2 for isolated DIPJ active range exercises.
Switch to dynamic PIPJ extension splint (eg, Capener) at 2 to 4 weeks; provide static splint for night wear.
Commence active flexion exercises in Capener
5 to 10 repetitions every 1 to 2 hours
Aim for 30° at week 2
Increase by 10° each week
If no PIPJ extensor lag, start to wean splint from week 5
Discard splint at week 6 and gradual return to normal activities by week 12
Extensor lag of greater than 30° may indicate failure of repair
Zone IV, V and VI (including sagittal band injuries)
Merritt yoke splint with 15° hyperextension of affected digit (appropriate for 1-3 digits)
Volar splint from mid forearm to PIPJs, with wrist in 30° to 40° extension and MCPJs in neutral
Commence active IPJ flexion and extension exercises immediately.
Wean splint from 4 to 6 weeks, discard at 6 weeks, build toward normal activities at week 12.
Zone VII and VIII
Manage in a volar splint from forearm to fingertips
Wrist in 20° (zone VI) to 45° (zone VIII) extension
MCPJs in 0° (neutral) extension
IPJs in neutral
Commence active IPJ flexion and extension exercises at week 2.
From weeks 3 to 4, remove splint for gentle wrist flexion/extension exercises.
Discard splint at week 6 and gradually build to normal activities by week 12.
Extensor pollicis longus
For zone I and distal zone II
Manage in an IPJ extension splint (eg, thermoplastic or Zimmer), keeping MCPJ free.
Commence isolated thumb flexion to 30° at week 3.
Commence active composite thumb flexion from week 6.
Avoid isolated passive IPJ flexion before week 8.
Discard splint at week 6 (unless there is a lag) and gradually increase exercise.
Return to normal activities at week 12.
For zone III to zone VIII
Manage in a volar splint with wrist in 20°, thumb comfortably abducted and extended, IPJ in neutral.
Commence active IPJ thumb flexion from week 4.
Avoid composite IPJ and MCPJ flexion (passive or active) before week 6.
Discard splint at week 6 and gradually increase exercise.
Return to normal activities at week 12.
Flexor Tendon Injuries
Goals of therapy and types of regimes
The ultimate goals of therapy following flexor tendon repair are to allow differential gliding of the flexor digitorum profundus and flexor digitorum superficialis tendons through a competent pulley system, in a finger which has a normal active and passive ROM and is free of pain and swelling.
The ideal repair is therefore strong enough to withstand motion at an early stage so that mobilization can occur prior to the onset of fibrosis and stiffness, and it is sufficiently smooth and low profile to eliminate drag as it passes through the tendon sheath.
Some tendon repairs will fail to meet at least one of these criteria, and so compromises must be made in rehabilitation. For the best quality repairs in motivated, compliant patients, the early active motion protocol may give the best outcomes. For more tenuous repairs, or repairs done in patients where communication, compliance, or motivation is an issue, there exist less demanding regimes which will also be described.
Early active movement/controlled active motion (EAM/CAM; Gratton/Sheffield/Belfast)
This is appropriate for repairs using four or more core strands plus an epitendinous suture, where the surgeon has indicated that there is no gapping and minimal bunching, and there is a good glide through the pulley system on-table.
Forearm-based dorsal splint to fingertips with wrist in 20° extension, MCPJs 30° flexion, IPJs in extension
Commence hourly exercises on days 3 to 5
10× passive flexion of IPJs and MCPJ
When good passive range, 10× active extension into splint, 10× gentle active flexion
Aim for one-quarter range in week 1, one-half range in week 2, full range in week 3
From week 3, concentrate on differential glide if passive range good using graduated hook grip and wrist tenodesis movements