Chapter objectives
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Apply rehabilitation guidelines to sports-related wrist and hand injuries.
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Describe the mechanism of injury and clinical picture with common hand injuries.
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Identify treatment pitfalls to help avoid poor functional outcomes.
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Apply rehabilitation principles for common wrist and hand injuries to advance an athlete from an acute phase of healing to return to sport.
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Choose appropriate splint types for specific wrist and hand injuries.
The purpose of this chapter is to provide a practical approach to the treatment of athletes with injuries involving their wrists and hands. Upper extremity injuries are often not given the full attention that they deserve because athletes resume participation after minimal care. However, left untreated, these injuries can result in permanent disability. Complete recovery to maximize function in performing daily tasks is the primary goal in the treatment of hand and wrist injuries. Fortunately, progress in surgical techniques, rehabilitation techniques, and custom splinting has allowed athletes to realize good functional outcomes.
The primary goal after a sports injury is to return the athlete to full participation as soon as possible without risking further injury or permanent disability. However, formal informed discussion about the potential long-term outcome of an undertreated hand or wrist injury should be a primary goal of the initial evaluation. The primary emphasis in this chapter is on the management of common wrist, hand, and finger injuries to minimize time until return to sport and prevent permanent disability or deformity.
In this chapter, common mechanisms of injury, pathologic characteristics of the involved structures, and clinical assessment of the injury are discussed. Practical management of the injury is presented with regard to evaluation, protective splinting, and initiation of rehabilitation. A summary of rehabilitation recommendations for each injury can be found in Table 14-10 . Exercises are described to help the clinician return the athlete to participation and maximize full functional performance of the injured structure. Consideration should always be given to the importance of evaluation and providing appropriate treatment of the entire upper extremity kinetic chain, as well as the body’s core, when rehabilitating an injured athlete. Whether a throwing athlete or not, a solid foundation in treating the upper extremity is essential to achieve normal mechanics for performing functional or sports activities after a hand or wrist injury. Failure to address weak trunk musculature, scapulothoracic dyskinesia, poor posture, neural tension or compression issues, and thoracic mobilization can result in further injury when return to sport is achieved.
| Injury and Location | Key Anatomic Structures | Splint Description | Splint Wear Schedule | Start Level I: AROM | Start Level I: PROM | Start Level II: Strength Program | Level III: Return to Sport |
|---|---|---|---|---|---|---|---|
| Mallet finger, fingertip | Terminal extensor mechanism | Custom Stax splint with DIP joint in full extension | 24 hr/day, 7 days/week for 8 weeks | 8 weeks | 10 weeks | 10 weeks | S/P injury with physician consent with 80% strength |
| Jersey finger with FDP repair, fingertip | Rupture of FDP tendon | Dorsal block splint with wrist at 20°-30° of flexion and dynamic finger flexion | 24 hr/day, 7 days/week for 4.5-6 weeks | 6 weeks | 8-10 weeks with physician consent | 8 weeks | 8-10 weeks with protective splinting and physician consent with 80% strength |
| Boutonnière, deformity of the PIP joint | Rupture of central slip | Finger-based splint for PIP joint only in full extension and disallowing movement | 24 hr/day, 7 days/week for 2-4 weeks * | 4 weeks | 6-8 weeks only with physician consent | 8-10 weeks with physician consent | S/P injury with physician consent with 80% strength |
| Pseudoboutonnière, PIP joint sprains and dislocations | Volar plate, collateral ligaments | Dorsal block splint with PIP joint in 30° of flexion | 24 hr/day, 7 days/week for 4-6 weeks * | 1-4 weeks | 6-10 weeks | 10-12 weeks | S/P injury with physician consent and protective splinting with 80% strength |
| Metacarpal fracture | Most common on the fourth or fifth metacarpal | Forearm-based ulnar gutter splint with the MCP joints in maximum flexion and the IP joints in maximum extension | 24 hr/day, 7 days/week for 4-6 weeks * | 4-6 weeks | 8-10 weeks | 8-10 weeks | 10-12 weeks with 80% strength |
| UCL sprain of the thumb | Sprain or rupture of UCL of the MCP joint of the thumb | Hand-based thumb spica splint with the thumb in midabduction and extension to protect the web space | 24 hr/day, 7 days/week for 4-6 weeks * | 6-8 weeks | 10-12 weeks | 10-12 weeks | 12 weeks with 80% strength |
| Bennett fracture | Fracture at the base of the thumb | Hand-based thumb spica splint with the thumb in midabduction and extension to protect the web space | 24 hr/day, 7 days/week for 6-8 weeks * Start rehabilitation if cleared by physician | 8-10 weeksAROM ADL therapy splint with sports | 10-12 weekscorrective splinting | 10-12 weeks start strengthening level II | 12 weeksFull sport if no pain and 80% strength |
| Scaphoid fracture | Fracture of the scaphoid located just distal to the radius | Forearm-based thumb spica splint with the thumb in midabduction and extension to protect the web space | 24 hr/day, 7 days/week for 12-16 weeks * | 8-12 weeksSplint to protect tender glide of digits | 12-16 weeksAROM of wrist if healed Cleared by physician | 14-16 weeksAdvance strength tasks | S/P injury with physician consent with 80% strength |
| Ganglion cyst | Fluid-filled cyst normally appearing on the dorsal radial surface of the wrist | Forearm-based wrist cock-up splint with the wrist in neutral to 10° of extension | 24 hr/day, 7 days/week for 2 weeks * | 0-2 weeksAROM | 3-6 weeksStrength | 7-10 weeksFull sports and splint | Return to sport with splint in 1 week with physician consent with 80% strength |
| Wrist sprain, TFCC injury | Located at the distal end of the ulna | Wrist gauntlet with the wrist in neutral to 10° of extension | 24 hr/day, 7 days/week for 8-12 weeks * | 4-6 weeks AROM of digit 3 | 8-12 weeksAROM of the digits | 12 weeksSlow progression in strength training if cleared by physician | 12+ weeks with 80% strength |
| de Quervain tenosynovitis | Tendonitis of the first extensor compartment | Forearm-based thumb spica splint with the thumb in midabduction and extension to rest the first extensor compartment | 24 hr/day, 7 days/week for 4-6 weeks * | 2-3 weeksNest with splint | 4-6 weeksTendon glides Grip strength | 6-8 weeksWork simulation | 6-8 weeks with 80% strength |
* Physician’s approval should be obtained before progression by all.
Mallet finger (distal interphalangeal tendon injury)
Mallet finger injury often occurs in ball-catching sports such as football, basketball, baseball, and softball. Typically, a ball or some object strikes the distal phalanx and forces it into hyperflexion while the extensor mechanism is active. A mallet finger deformity is readily observed because the athlete is unable to actively extend the distal phalanx. Additional clinical signs of this injury are listed in Box 14-1 . McCue classified mallet finger into five types ( Table 14-1 ). Indications for physician referral include the following:
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Extensor lag of the distal interphalangeal (DIP) joint
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Passive range of motion (ROM) greater than active ROM (AROM) extension of the DIP joint
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Pain and swelling focal to the DIP joint
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Ligamentous instability
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Painful passive compression of the finger; radiographs must be obtained to rule out fractures
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Absence of hyperextension of the proximal interphalangeal (PIP) joint
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Need for surgical treatment for type IV and V injuries
The athlete is unable to actively extend the distal phalanx.
Radiographs must be obtained to rule out the presence of a fracture, but it is not generally necessary to acquire radiographs immediately.
Crepitus and point tenderness in the distal phalanx are classic signs of a fracture.
Along with the fracture, the digit may have a subungual hematoma.
| Type | Injury |
|---|---|
| I | Tendon stretch |
| II | Tendon rupture |
| III | Tendon rupture with avulsion of the distal phalanx |
| IV | Distal phalanx fracture involving the articular surface |
| V | Epiphyseal fracture |
Open mallet injuries may require surgical débridement to prevent infection and surgical repair of the damaged soft tissues to restore the biomechanics of the joint. Table 14-2 lists considerations for splint use and pitfalls in the treatment of a mallet finger.
| Joint Position | Conservative Treatment by Splinting the DIP Joint in Full Slight Hyperextension |
|---|---|
| Duration of splint wear | 6 to 8 weeks of constant splinting, acute injury |
| Splinting for competition | 3 additional weeks monitored by a physician |
| Splint type | DIP dysfunction tendon injury: a variety of splints, including commercially available dorsal or volar aluminum and custom-made thermoplastic (preferred) (see Fig. 14-1 ) |
| Pitfalls of treatment | Poor understanding and poor healing rate of the distal extensor mechanism, which has a negative impact on compliance with the treatment protocol Flexion occurring at any time during the immobilization phase: the 8-week immobilization period starts again from that day and may need to be longer Fracture malunion as a result of poor compliance DIP joint splinted into extreme hyperextension, which may cause an impairment of the blood supply to the skin and result in skin sloughing over the DIP joint Heavy scar tissue formation The splint and skin must be kept dry to prevent maceration Infection or skin irritation because of poor splint fit |
| Goals of treatment | Protect the distal extensor mechanism, fracture, or joint dislocation Avoid deformity Preserve dexterity and strength Maintain independence in ADL tasks |
Treatment of mallet finger depends on the type of injury that the DIP joint and extensor mechanism have sustained. If an open dislocation has occurred, care is taken to prevent wound infection. Initial swelling can be managed with the use of a Coban wrap * ,
* Available from 3M, St. Paul, MN.
application of ice, elevation, and motion of the unaffected joints and digits while wearing a protective splint ( Fig. 14-1 ). The athlete must be supervised and instructed to keep the DIP joint in full extension at all times during the 8-week course of treatment.Regular splint removal after a mallet finger injury is necessary to keep the area under the splint clean and dry and to ensure skin integrity. It is imperative that the athlete maintain joint extension during this cleaning process. The splint must be worn continuously for 6 to 8 weeks to achieve a good functional outcome.
After the initial 8 weeks of continuous splinting, the athlete is advised to continue wearing the splint during athletic activities for 6 to 8 more weeks with assurance that return to sport has been authorized by the physician. Athletes participating in a formal rehabilitation program may not realize full ROM of the DIP joint with an intraarticular fracture. Consult Tables 14-9 and 14-10 for an expected time line for return to sport.
| Level | Activity | Load | Pace | Goal |
|---|---|---|---|---|
| Level I: Restoration and balance phase (inflammatory and proliferation phase of healing) | Rest with a custom splint ADL fine motor dexterity training (lacing, buttoning, pegboard) Tendon glides (see Fig. 14-13 ) Nerve glides (avoid increase in pain or symptoms) Scapular and posture awareness (to increase proximal stability) Resume cardiovascular training if no open wounds | No load to avoid increasing the inflammatory phase of healing Sedentary functional tasks conducted below shoulder level | Therapist directed Self-paced | Athlete education on potential loss of function and need for compliance Establish a balance of hand function to minimize potential for deformity Maximize tendon excursion Treat edema Desensitize scar tissue Maintain neuromotor control Independence in self-care activities Postural control |
| Level II: Load and correction phase (maturation phase of healing) | Focus on strengthening linear motion patterns of the wrist and arm below shoulder level Thera-Putty Isometric grip and hold Isotonic wrist flexion and extension Core stability of proximal stabilizers critical to establish during this rehabilitation phase Closed kinetic chain exercises Continue level I tasks | Increase in physical demand level load from sedentary to light, light medium Increase in duration of rehabilitation activity from 1-2 hours total | Self-paced | Increase motor control Increase work capacity of injured structures in preparation for strength and conditioning program Start measures to correct joint deformities Eliminate compensatory movement patterns Master postural control |
| Level III (return-to-sport phase); level considered to be the highest level of function | Use of dynamic functional sport simulation tool Exposure to dynamic open kinetic chain strengthening tasks Overhead weight lifting Ulnar and radial deviation Pronation and supination | Increase in physical demand level load from medium to heavy | Sport pace | Maximize motor control Safe return to sport |
* Based on healing rates of involved tissues. The levels of care can provide clear communication on the hierarchic plan for functional return between clinicians and physicians during the rehabilitation process. This communication will help minimize the chance of overloading the recovering tissue, thereby producing a setback, which occurs easily in hand rehabilitation. Consultation with the team physician should be considered before a change in level.
Jersey finger (flexor digitorum profundus rupture)
An athlete may sustain this injury when attempting to tackle an opponent if a digit is caught in the opponent’s jersey while the opponent is breaking away. The flexor digitorum profundus (FDP) tendon undergoes eccentric loading at the distal phalanx with the force exceeding the tendon’s tensile strength. This can create an avulsion of the FDP tendon at the insertion of the distal phalanx. The injury can occur at any finger, but most commonly the ring finger is involved because of the longer length of the digit when grasping objects.
Physical examination of this injury requires isolating the function of the flexor tendons. The FDP is isolated by blocking PIP joint motion while actively flexing the DIP joint. Inability to isolate and actively flex the DIP joint should raise suspicion for FDP injury. Palpating for the retracted tendon along the flexor sheath is important for identifying the level of retraction. Jersey finger is classified by Leddy and Packer into three levels of retraction ( Table 14-3 ), with type I injury being most severe.
| Type | Amount of Retraction | Time to Repair |
|---|---|---|
| I | Retracted to the palm | 7 days |
| II | Retracted to the PIP joint | 10 days |
| III | Avulsion of the distal phalanx | 2 weeks |
Management of a jersey finger injury depends on the level of tendon retraction (available blood supply from an intact vinculum), delay in repairing the injury, future sports career plans, philosophy of the treating physician, and the athlete’s commitment to participate in the rehabilitation protocol after surgery. Common pitfalls that can occur in the management of this injury are described in Table 14-4 .
| Consideration | Pitfall |
|---|---|
| Human and anatomic factors | Compliance is poor. Adhesions of digital tendons impede flexion and extension of the fingers. Quadriplegia (diminished ability to create movement because of adverse effect of the pathologic condition on common muscle belly performance) may occur. Intrinsic tightness will result in loss of dexterity and grip strength. Extrinsic tightness will result in loss of gross motor dexterity of the wrist and strength of the hand. |
| Splinting | Awareness of flexion contractures of the PIP joint is inadequate, and it is often untreated. |
| Treatment | Injury is often missed because of soft tissue trauma. Postsurgically, the athlete must have the capacity to passively flex all fingers to the palm and actively extend the fingers to the dorsal block splint before leaving the first treatment session. Extreme edema may impede early tendon gliding and should be an early primary treatment goal. The athlete must be cautioned to not allow the fingers or wrists to actively flex or extend outside the protected dorsal block splint. |
Flexor tendon injuries should be monitored by a physician and a trained certified hand therapist (CHT) for the first 8 to 10 weeks to maximize the athlete’s functional outcome. The Kleinert method of dynamic digital flexion can be used to assist in the rehabilitation process ( Fig. 14-2 ). A dorsal block splint is custom-fabricated by a CHT to protect the repaired tendon from excessive stress associated with wrist and digital extension. The fingertips are passively flexed to the palm with rubber bands attached to the fingernails via hooks and adhesive. This passive flexion ROM pushes the repaired tendon proximally, reduces stress on the repair, and promotes tendon glide. The exercise program consists of passive ROM with dynamic flexion to the palm followed by active extension. Active extension against the dynamic flexion creates reciprocal inhibition and thus reduces stress on the repair and relaxes the repaired flexor tendon. The athlete exercises with the dorsal block splint in place at all times for the first 6 weeks. Joints with excessive edema require a graded and slower approach to realize full passive flexion. These athletes should be seen more often to ensure that full active extension and passive flexion motion is achieved early in rehabilitation. A modified Klienert and Duran postoperative rehabilitation protocol after repair of a torn FDP is described in Table 14-5 . The presurgical and postsurgical rehabilitation programs include a focus on control of edema with compression, elevation, and protected movement based on the selected protocol ( Fig. 14-3 ), as well as education of the athlete with regard to long-term disabilities, precautions, and appropriate compliance with the rehabilitation protocol.
Stress on the FDP tendon repair at 6 to 8 weeks should occur slowly with a focus on AROM, avoidance of joint stiffness, and management of scar pain and adhesions ( Fig. 14-4 ). The tendon repair will be at half strength 12 weeks after surgery.
| 3 Days-3 Weeks | 4½–6 Weeks | 6 Weeks | 8-10 Weeks | 10-12 Weeks | |
|---|---|---|---|---|---|
| Splint | Wrist placed in a dorsal block splint Wrist placed in 20° of flexion MCP joints placed in 60° of flexion IP joints placed in maximum extension Dynamic traction via a daytime palmar pulley with nighttime resting strap | Dorsal block splint can be worn at night Postoperative flexor tendon splint can be worn during the day. This splint provides finger pulley flexion to palm all digits and allows wrist flexion and extension | Dorsal block splint and postoperative flexor tendon splint can be discontinued | Protective DIP joint splint at 30° of flexion to be used with gross motor strengthening activities and athletic activities | Buddy tape for functional activities that exceed a medium demand level (25 lb) with one hand Use protective DIP joint splint when performing competitive activities At 12 weeks all splints can be discontinued |
| Levels of Care | 0 3 Days-3 Weeks | I 4½–6 Weeks | I and II 6 Weeks | II 8-10 Weeks | III 10-12 Weeks |
|---|---|---|---|---|---|
| Exercise | Active extension of IP joints to the hood of the splint, 8 repetitions every hour without traction through the palmar pulley Passive flexion of the digits, working toward a full fist and isolated MCP, PIP, and DIP flexion; 10 repetitions 4-6 times per day in the splint | Emphasize tendon gliding with basic four hand postures: dorsal compartment ROM (elbow extended, pronated; full fist; actively flexed wrist)Volar compartment ROM (elbow extended, supinated; fingers extended; actively extended wrist) | Continue intrinsic and extrinsic compartment stretching Passive overpressure exercise can be used in a protected posture (flexed wrist to stretch the lumbricals) | Start isometric and isotonic strengthening: Thera-Putty Functional passive ROM to restore intrinsic and extrinsic motion without protective postureStart pushing activities (push-ups and bench press) and general conditioning tasks but avoid pulling exercises | Continue progressive strengthening exercises Continue stretching exercises to regain full motionStart sport-specific training activities, including pulling exercises, in preparation for return to full sport participation |
| Precautions | No lifting, carrying, pushing, or pulling done with the repaired hand | No lifting, carrying, pushing, or pulling done with the repaired hand | Self-care activities at a sedentary physical level (not to exceed 5 lb) | Activity progressed to a light physical demand level (not to exceed 10 lb) | Ballistic pulling tasks with force greater than 20 lb |
| Special considerations | Use a Coban wrap to control edema At 2 weeks postoperative, the fingers can be placed in a fist-like posture and AROM of wrist flexion and extension initiated (with the therapist) Avoid the pain reflex with aggressive rehabilitation | Biofeedback training for fine motor and gross motor self-care tasks; need physician’s clearance before starting AROM | Neuromotor reeducation Light resisted activities for increasing motor output of the flexor tendons | Explore correction of joint flexion deformity if present with physician’s consent Scapular stabilization is key to focal movement of flexor tendons | Pushing tasks for conditioning can exceed pulling tasks |
Boutonnière injuries (extensor tendon injury of the proximal interphalangeal joint)
A boutonnière deformity is a flexion deformity of the PIP joint with a hyperextension deformity of the DIP joint. Common mechanisms of injury include a direct blow to the dorsum of the PIP joint or forced flexion of the PIP joint while the extensor mechanism is actively extending the joint (e.g., opening the hand to catch a pass and being struck on the dorsum of the hand at the same time). This deformity can occur as a result of lengthening or complete rupture of the central slip at the PIP joint. Swelling from the traumatic injury can displace the lateral bands volarly and further retract the ruptured extensor mechanism.
Anatomically, the central slip of the extensor mechanism is ruptured at the base of the middle phalanx. The extensor mechanism may glide volar to the axis of the PIP joint. The injury can change the mechanical function of the extensor mechanism to a flexor of the PIP joint. This change coupled with unopposed action of the flexor digitorum superficialis (FDS) results in the boutonnière deformity.
In acute injuries, it is difficult to differentiate a PIP joint sprain from a boutonnière injury. With either injury, swelling, pain, and an inability to actively extend the PIP joint can be noted. A digital block performed by a physician can limit the inhibiting effect of the pain and assist in detection of a ruptured extensor mechanism. An extension lag at the PIP joint of greater than 15° after injury as a result of joint or contractile tissue problems is an indication for referral to a specialist. Surgical repair is rarely an option because the results are less predictable than with conservative management. If this injury goes untreated or is managed as a PIP joint sprain by splinting the finger in slight flexion, a boutonnière deformity can occur. Other complications that may develop if this injury is not diagnosed appropriately include volar plate tightness, oblique retinacular tightness, and adhesions of the lateral bands. PIP joint dysfunction can result in loss of dexterity and long-term stiffness. A variety of splinting techniques are used to treat a PIP joint contracture. If a soft end-feel is present and contracture of the PIP joint is less than 35°, a custom static progressive splint may be used. If a firm end-feel contracture of greater than 25° is present, serial casting is recommended to stress the dense connective tissue contracture and correct the extension lag. Splints that correct dense connective tissue should be provided by a CHT to maximize extension and avoid skin breakdown ( Fig. 14-5 ). When full extension is achieved, the PIP joint is splinted continuously in full extension for 4 more weeks, and AROM exercises for the DIP and metacarpophalangeal (MCP) joints are then started.
