Rehabilitation of Hand and Finger Fractures

15 Rehabilitation of Hand and Finger Fractures

Jürgen Mack

Abstract

Hand therapy, like hand surgery, has developed into a separate discipline in physical therapy. For successful treatment, the problems that can occur must be taken into consideration in order to be able to react with the appropriate measures. This is only possible if we specialize in hand therapy and have experience in this area of expertise. In rehabilitation of fractures of the wrist, metacarpals and the fingers, a detailed assessment is very important. This is the basis for the treatment in order to proceed to an appropriate therapy method. For a good result, treatment should start as soon as the surgeon allows the therapy to begin. The next step for the therapist is to use the right techniques, which will vary depending on the location and classification of the fracture. There are different techniques that may be used for the wrist, metacarpals and the fingers. Moreover, it depends on what the patient can cope with. There should be regular assessments to get feedback on the progression. A valuable key point for a successful treatment is for the patient to be always informed regarding the therapy and to be provided with homework. The exercises must be thoroughly explained to the patient and the progress should be monitored regularly. If all these steps are strictly followed, a good result can be accomplished.

Keywords: assessment, techniques, treatment for fractures in the wrist/metacarpals/fingers, home exercises, problem solving

15.1 Challenges in Rehabilitation of Hand and Wrist Fractures

There are several specific problems in hand rehabilitation, some of which are the following:

• Beginning too late with the therapy causes stiffness of the fingers and the wrist.

• Being in a resting position for too long also causes stiffness of the fingers and the wrist.

• Immobilization in a wrong position leads to stiffness as well. Usually, patient tends to hold their fingers in flexion so they have less pain. But only intrinsic plus position avoids contractures.

• Improper healing of the bones (nonunion or malunion).

• Avoiding rotational deformity with scissoring of the fingers when making a fist.

• Persistent swelling.

• Inadequate exercises of the patient (bad compliance).

• Beginning of complex regional pain syndrome (CRPS).

15.2 Patient Evaluation before Therapy

An extensive assessment of the patient is required before therapy. It should include the following information from the patient and the doctor:

• The date of assessment.

• The date of the trauma or operation.

• Taking pictures of the hand, to locate where the problems are: wrist/metacarpals/finger and left or right hand.

• Description of trauma mechanism: how and where it happened (at work, during sports, at home).

• Type of fracture: straight/oblique/debris/, affected joint.

• Age of the patient.

• If it is the dominant hand, the therapy is significant to decide when the patient can go back to work or carry on with sport.

• Profession, to be able to decide accordingly when work can be resumed.

• Hobbies, so the patient is able to use his fingers during his favorite activities.

• Smoker or nonsmoker.

• Pain classification, quality and exact location so we can decide if it is a regional pain syndrome or a peripheral pain.

• Instruction from the surgeon, guidelines for the treatment.

• Is the patient wearing a splint and has he been properly instructed how to wear it?

• X-rays, especially if the patient had surgery. We have to see where the wires and screws are (finger and metacarpal, close to a joint) or a plate at wrist fractures.

15.2.1 Tools for Measurement

For measurement of the angle, we use the neutral zero method with the finger goniometer ( Fig. 15.1). An alternative is the documentation on pictures that are taken at regular intervals ( Fig. 15.2).

Fig. 15.1 The neutral zero method.

Fig. 15.2 Taking pictures for comparing both sides.

15.2.2 Measuring the Hand Span Distance and Incomplete Closure of the Fist

At the thumb, the distance between the thumb tip and the fingertip of the second finger is measured ( Fig. 15.3) for measuring the first webs pace. For handspan evaluation, the distance between the tips of the thumb and the fifth finger is measured while spreading the fingers as far as possible.

The distance from the fingertip to the distal flexion crease of the palm can be measured with the fingers ( Fig. 15.4).

15.2.3 Neurological Evaluation

In the case of neurological signs, the 2-point discriminator can be used to measure the nerve innervation density ( Fig. 15.5); monofilaments with different pressure intensities can be used to measure the sensitivity ( Fig. 15.6) and we use the Tinel sign to test the renervation process ( Fig. 15.7).

Fig. 15.3 Thumb to index distance.

Fig. 15.4 Finger-hollow of the hand distance.

15.2.4 Circumference and Volume

In the acute phase, the circumference is measured with the tape measure ( Fig. 15.8). When the wound healing is complete, the hydrometer can be used ( Fig. 15.9).

15.2.5 Measuring Force with the Jamar Dynamometer

To measure the hand force, the Jamar dynamometer is used ( Fig. 15.10).

15.3 Techniques Used in Rehabilitation

15.3.1 Manual Therapy

An essential part of hand therapy is mobilization with manual therapy. With this therapy, we improve the rolling and gliding of the partners involved in the movement. This is shown in Fig. 15.13: fixation of the forearm and the distal carpal row is moved dorsally. Fig. 15.14 shows the fixation of the head of the second metacarpal and the proximal phalanx which is displaced dorsally and ventrally.

Fig. 15.5 Two-point discriminator, static or dynamic.

Fig. 15.6 Monofilaments.

Fig. 15.7 Tinel’s sign.

Fig. 15.8 Hydrometer.

Fig. 15.9 Using a measuring tape.

Fig. 15.10 Using a dynamometer.

To be able to work with manual therapy, we have to know the exact location and classification of the fracture. The X-ray images are very important ( Fig. 15.11).

The fixation for mobilization of the finger or the wrist depends on where the fracture is ( Fig. 15.12).

For the right position, we need a wedge and good positioning of the patient.

For the therapy, we need a stable storage and exact grip techniques ( Fig. 15.13 and Fig. 15.14).

15.3.2 Flossing

For this method, we use broad elastic rubber bands. We wrap the finger from distal to proximal. It has to be wrapped very tightly. Once it is wrapped, we start moving the joints ( Fig. 15.15), which creates pressure on the tissue and helps solve the problems of adhesions and nonphysiological crosslinks.

The finger will be wrapped for 2 minutes ( Fig. 15.16). During this time, the finger is moved in flexion and extension.

Another effect is increased lymph flow and softened scar tissue.

A good example for using flossing is when the movement does not improve. There is no scientific evidence yet, but practical experience has shown this method to be effective.