Rehabilitation of Wrist, Hand, and Finger Injuries

Anne Marie Schneider, OTR/L, CHT

The hand is an intricate balance of muscles, tendons, and joints working in unison. Hands are almost always exposed and for that reason can be especially prone to injuries, especially during sport contact.38 Changing the mechanics can greatly alter the function and appearance of the hand.

The Wrist

The wrist is the connecting link between the hand and the forearm.³⁵ The wrist joint is composed of 8 carpal bones and their articulations with the radius and ulna proximally, and the metacarpals distally. There is an intricate relationship between the carpal bones. They are connected by ligaments to each other and to the radius and ulna. The palmar ligaments from the proximal carpal row to the radius are strongest, followed by the dorsal ligaments (scaphoid-triquetrum, and distal radius to lunate and triquetrum), with intrinsic ligaments (scapholunate and lunotriquetral) being the weakest.³⁴ The carpal bones are arranged in 2 rows, proximal and distal, with the scaphoid acting as the functional link between the two.³⁵ The distal carpal row determines the position of the scaphoid and thus the lunate. With radial deviation, the distal row is displaced radially while the proximal row moves ulnarly. The distal portion of the scaphoid must shift to avoid the radial styloid. The scaphoid palmar flexes. This is reversed in ulnar deviation.³⁵ The total arc of motion for radial and ulnar deviation averages about 50 degrees, 15 degrees radially and 35 degrees ulnarly.³⁵ The uneven division is due to the buttressing effect of the radial styloid.³⁵

Flexion and extension occur through synchronous movement of proximal and distal rows. The total excursion is equally distributed between the midcarpal and radiocarpal joints.³⁰ The arc of motion for flexion and extension is 121 degrees.⁴⁰

There are no collateral ligaments in the wrist. Their presence would impede radial and ulnar deviation, allowing only flexion and extension. Cross sections through the wrist reveal that tendons of the extensor carpi ulnaris (ECU) at the ulnar aspect of the wrist and the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) on the radial side are in “collateral” position.⁴⁰ Electromyogram studies show that ECU, EPB, and APL are active in wrist flexion and extension.⁴⁰ These muscles show only small displacement with flexion and extension so they are in an isometric position.⁴⁰ Their function can be described as an adjustable collateral system. The ECU shows activity in ulnar deviation and the APL and EPB in radial deviation.⁴⁰

Stability of the ulnar side of the wrist is provided by the triangular fibrocartilage complex (TFCC).⁹ This ligament arises from the radius and inserts into the base of the ulnar styloid, the ulnar carpus, and the base of the fifth metacarpal.⁹ This ligament complex is the major stabilizer of the distal radioulnar joint (DRUJ) and is a load-bearing column between the distal ulna and ulnar carpus.³ There are no muscular or tendinous insertions on any carpal bones except the flexor carpi ulnaris (FCU) into the pisiform.³⁵ Muscles that move the wrist and fingers cross the wrist and insert on the appropriate bones. There is a dorsal retinaculum (fascia) with 6 vertical septa that attach to the distal radius and partition the first 5 dorsal compartments.^35,40 These define fibro-osseous tunnels that position and maintain extensor tendons and their synovial sheaths relative to the axis of wrist motion.⁴⁰ The sixth compartment that houses the ECU is a separate tunnel formed from infratendinous retinaculum. This allows unrestricted ulnar rotation during pronation and supination.⁴⁰ The retinaculum prevents bowstringing of the tendons during wrist extension.

Volarly, the long finger flexors, long thumb flexor, median nerve, and radial artery pass through the carpal tunnel. Bowstringing is prevented by the thick transverse carpal ligament.

The Hand

The metacarpal phalangeal (MCP) joints allow for multiplanar motion; however, the primary function is flexion and extension.³⁰ The metacarpal head has a convex shape that fits with a shallow concave proximal phalanx.The stability of the MCP joint is provided by its capsule, collateral ligaments, accessory collateral ligaments, volar plate, and musculotendinous units.30 The collateral ligaments are laterally positioned and are dorsal to the axis of rotation. In extension the collateral ligament is lax, in flexion it is taut.¹⁰ This is important to remember if immobilizing the MCP joint. If the joint is casted or splinted in extension, the lax collateral ligament will tighten, which will then prevent flexion once mobilization has begun. The accessory collateral ligament is volar to the axis of rotation and is taut in extension and lax in flexion.

The volar plate helps prevent hyperextension of the MCP joint. It forms the dorsal wall of the flexor tendon sheath and the A1 pulley.¹⁰

Several muscles cross the MCP joints. On the flexor surface, the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) are held close to the bones by pulleys. These pulleys prevent bowstringing during finger flexion.⁵⁰ The FDS flexes the proximal interphalangeal (PIP) joint, and the FDP flexes the distal interphalangeal (DIP) joint.⁵⁰ The interosseous muscles are lateral to the MCP joints and are responsible for abduction and adduction of the MCP joints. The lumbrical muscles are volar to the axis of rotation of the MCP joint, but then insert into the lateral bands and are dorsal to the PIP and DIP joints. Their function is MCP joint flexion and IP joint extension. (This is also the reason there can be IP extension with a radial nerve palsy.) Dorsally, the extensor mechanism crosses the MCP joint. The tendon is held centrally by the sagittal bands.⁴⁶

The Fingers

The IP joints are bicondylar hinge joints allowing flexion and extension. Collateral and accessory collateral ligaments stabilize the joints on the lateral aspect.³³ The collateral ligament is taut in extension and lax in flexion. This is important when splinting the PIP joint. If it is not a contraindication to the injury (ie, PIP fracture dislocation), the joint should be splinted in full extension to help prevent flexion contractures.

On the flexor surface, the FDS bifurcates proximal to the PIP joint, allowing the FDP to become more superficial as it continues to insert on the distal phalanx, allowing DIP flexion. The FDS inserts on the middle phalanx for PIP flexion. Five annular pulleys and 3 cruciate pulleys between the MCP and DIP joints prevent bowstringing of the tendons and help provide nutrition to the tendons.

On the extensor surface, the common extensor tendon crosses the MCP joint then divides into 3 slips.⁴⁰ The central slip inserts on the dorsal middle phalanx, allowing for PIP extension. The 2 lateral slips, called the lateral bands, get attachments from the lumbricals, travel dorsal and lateral to the PIP joint, rejoin after the PIP joint, and insert as the terminal extensor into the DIP joint. This is a delicately balanced system to extend the IP joints. Disruption of this system greatly alters the balance, and thus the dynamic function, of the hand.

REHABILITATION TECHNIQUES FOR SPECIFIC INJURIES

Distal Radius Fractures

Pathomechanics

Fractures of the distal radius can be described in many different ways, by several classification systems. For treatment, it is important to be able to describe the fracture and X-ray. Is the fracture intra-articular or extra-articular, displaced or nondisplaced, simple or comminuted, open or closed? Is the radius shortened? Is the ulna also fractured? Answers to these questions help guide treatment and expected outcomes.

Simple, extra-articular, nondisplaced fractures tend to heal without incident with immobilization, with full or nearly full motion expected following treatment.² As the fractures become more involved (intra-articular or comminuted), chances of full return of motion are decreased.

The normal anatomic radius is tilted volarly. If in a fracture the volar tilt becomes dorsal, motion will be affected. It can also lead to midcarpal instability, decreased strength, increased ulnar loading, and a dysfunctional DRUJ.²⁸

The normal anatomic radius is longer than the ulna. If in a comminuted fracture the radius is shortened, this is the most disabling.²⁸ Radial shortening can lead to DRUJ problems, decreased mobility, and decreased power (strength). Articular displacement correction is critical. Radial shortening must be corrected via external fixation.

As is true of most wrist injuries, distal radius fractures occur from a fall on an outstretched hand.38 It might be a high-impact event but does not have to be.

Rehabilitation Concerns

Early and proper reduction and immobilization are of utmost importance. The fracture must be closely watched initially to be sure reduction is being maintained. Early ROM to noninvolved joints is imperative. This helps prevent muscle atrophy, aids in muscle pumping to decrease edema, and most importantly, maintains motion so treatment can focus on the wrist once the fracture is healed and fixation is removed.²

Other concerns include complications of carpal tunnel or complex regional pain syndrome.²⁸ If present and first noted in the therapy clinic or athletic training room, referral should be made back to the physician as soon as possible. One other complication, which usually occurs late in a seemingly inconsequential nondisplaced distal radius fracture, is an extensor pollicis longus (EPL) rupture.²⁸ It is thought that this occurs from the EPL rubbing around the fracture site near Lister’s tubercle. The patient would be unable to extend the thumb IP joint. The test for this is to put the injured hand flat on the table and try to lift the thumb off the table toward the ceiling. The term for this movement is retropulsion (Figure 19-10). This would need to be surgically repaired.

Rehabilitation Progression

Rehabilitation may be initiated while the wrist is immobilized. This should include shoulder ROM in all planes, elbow flexion and extension, and finger flexion and extension. Finger exercises should include isolated MCP flexion, composite flexion (full fist), and intrinsic minus fisting (MCP extension with PIP flexion; Figure 19-18). Coban (3M) or an Isotoner (Isotoner Inc) glove may be used for edema control if necessary.

If a fixator or pins are present, pin site care may be performed, depending on physician preference. Many physicians prefer hydrogen peroxide with a cotton applicator to remove the crusted areas from around the pins. A different applicator should be used on each pin, to prevent possible spread of infection. Some physicians allow patients to shower with the fixator in place (not soaking while bathing); other physicians prefer to cover the pin sites with a plastic bag to keep them dry.

Once immobilization is discontinued (at about 6 weeks for casting, 8 weeks with an external fixator, 2 weeks for ORIF with plate and screws), ROM to the wrist is begun. Active motion is begun immediately. Wrist flexion, extension, and radial and ulnar deviation are evaluated, then instructed. Wrist extension should be taught with finger (especially MCP) flexion (Figure 19-1). This isolates the wrist extensors and prevents “cheating” with the extensor digitorum communis (EDC). The importance of wrist extensor isolation is for hand function. If the EDC is used to extend the wrist, then flexing the fingers to grasp something will cause the wrist to also flex, because there is not enough wrist strength to keep the wrist extended. Tenodesis will extend the fingers, and the object will be dropped. Isolating wrist extension should be the emphasis of treatment on the first visit.

Passive ROM may depend on physician preference. Many let passive ROM begin immediately, others prefer waiting 1 to 2 weeks (Figures 19-1D and 19-2D) for passive stretching exercises. Forearm rotation (supination and pronation) must not be ignored. Active and passive ROM are both important. When stretching rotation passively, pressure should be applied at the distal radius, proximal to the wrist, not at the hand. This will help apply pressure where the limitations are and not put unnecessary torque across the carpus (Figures 19-5C and 19-6C).

Active motion can be progressed to strengthening. Light weights, TheraBand (Performance Health), or tubing may be graded for all wrist and forearm motions. This can be in conjunction with or in a progression to closed chain weightbearing activities. Start with wall push-ups, then progress to countertop or table, then to floor (Figures 19-12 through 19-14). Push-ups on a stability ball may be the next progression (Figure 19-23), along with kneeling on the floor and bearing weight on a BAPS board (Spectrum Therapy Products) while shifting weight (Figure 19-24).

Using putty for grip strengthening can be started and upgraded to harder putty beginning about 1 to 2 weeks after immobilization. This also helps to strengthen the wrist musculature (Figure 19-11A).

Plyometric exercises for the wrist and general upper extremity strength are next. Activities are graded from a playground-type ball to a large gym ball to weighted balls. Activities can be done supine, against a wall, or, if available, using a rebounder. Specific return-to-sport exercises and activities must also be done.

Criteria for Return

Return to play depends on the sport and the severity of the fracture. If the fracture is nondisplaced, the patient usually may return to sport when it stops hurting (2 to 3 weeks, or sooner), with protection. There should be early signs of healing, no pain at rest, and no pain with a direct blow to the protection. If a nondisplaced fracture is treated by ORIF with plate and screw fixation, the patient might be able to return to play at about 3 weeks without protection if the sport is noncontact or with protection if a contact sport. At about 6 weeks, the patient may play without protection. The sport must be taken into consideration. An athlete in a high-contact sport might need protection longer than a patient in a noncontact sport. If the fracture was displaced, the patient is usually out of competition for about 6 weeks, then returns with protection for an additional 2 to 6 weeks (Figures 19-25 and 19-26). As with all injuries, return to sport depends on the sport, position played, and physician. The patient’s strength must also be adequate for the position played, to prevent reinjury.

Wrist Sprain

Pathomechanics

The term wrist sprain is often seen when patients complain of pain and have a history of minor trauma. The diagnosis should be one of exclusion. Injuries that must be ruled out include scaphoid fracture, traumatic instability patterns, lunate fractures, dorsal chip fractures, other carpal fractures and injuries, and ligament tears.³⁰

Injury Mechanism

The injury is usually a minor trauma, either a fall landing on an outstretched hand, a twisting motion, or some impact such as striking the ground with a club.³⁸

Rehabilitation Concerns

The primary concern is ruling out more serious injury. Once other diagnoses are ruled out, treatment is focused on edema control, pain control maintaining (or increasing) active and passive ROM to the wrist and other, noninvolved joints. If necessary, splint immobilization (Figure 19-25) may also be tried for pain relief. If activities increase pain, those activities should be examined to determine whether modifications can be made to decrease pain and increase activity level for return to sport.

Following decrease in pain and edema, and return of ROM, strengthening should be performed to all wrist motions and, if necessary, to grip strength and entire arm. Refer to the section on distal radius fracture for specific exercises (Figures 19-1 through 19-14, 19-23, and 19-24). Joint mobilizations for the wrist can certainly help improve joint arthrokinematics and ROM (see Figures 13-26 through 13-30).

Criteria for Return

Patients may return to sport when comfortable. Taping the wrist (Figure 19-26) can help provide support and decrease pain. The patient should not return to play until all other serious conditions are ruled out.

Triangular Fibrocartilage Complex

Pathomechanics

The TFCC is the primary stabilizer of the radioulnar joint. It consists of dorsal and volar radioulnar ligaments, ulnar collateral ligament (UCL), meniscus homologue, articular disc, and ECU tendon sheath.⁹ The TFCC functions as a cushion for the ulnar carpus and a major stabilizer of the DRUJ. The TFCC arises from the radius and inserts into the base of the ulna styloid. It flows distally (UCL), becomes thickened (the meniscus homologue), and inserts distally into the triquetrum, hamate, and base of the fifth metacarpal.⁹ Blood supply to the TFCC is limited to the peripheral 15% to 20%. The central articular disc is relatively avascular.⁹ Generally, the TFCC tears that occur traumatically are in the periphery and can be surgically repaired because of the blood supply. Most degenerative tears are central and are best treated by debridement.

Injury Mechanism

Injuries to wrist ligaments can occur after a collision on the field, a fall on an outstretched hand, a pileup on the field where the wrist is landed on and twisted, or hitting a bad shot in tennis or golf.⁴⁴

Rehabilitation Concerns

The primary concern is correct diagnosis. The patient will usually present with ulnar-side wrist pain. There may have been an acute injury or just pain from overuse. ROM should be evaluated actively and passively. Pain is usually present with extension, ulnar deviation, and forearm rotation.⁵¹ Palpation to replicate pain should be performed. Start with the radial side of the wrist, away from the pain. Palpate the snuffbox for scaphoid pain, dorsally for scapholunate ligament pain, ulnar to that (just proximal to the third metacarpal) for lunate pain, then palpate over the ulna head, just distal to the ulna head, and on the ulnar border of the wrist. Joint mobilizations of the carpus on radius can be performed. This is followed by ulna on radius in neutral, then in supination, then in pronation. You are looking for reproduction of pain and excessive movement on any direction compared to the noninjured side. An MRI or wrist arthroscopy can confirm the diagnosis. If an acute injury not associated with significant separation from the radius or ulna, it can be treated by cast immobilization.⁶ A peripheral tear of the radial or ulnar attachments should be repaired. There is good blood supply, and it has the potential to heal.⁴² A central linear or flap tear can be arthroscopically debrided with good results.⁵¹

Rehabilitation Progression

A patient who has had surgery for repair of the TFCC will be in a postoperative dressing for 10 days to 2 weeks. At that time, the sutures will be removed, and the patient will be placed into a protective splint. The author makes a circumferential wrist splint that immobilizes the wrist and goes two-thirds of the way up the forearm, leaving the fingers and thumb free. A second splint is then applied around the elbow and overlapping the wrist splint (Figure 19-27). This is to prevent supination and pronation. Some surgeons keep the arm immobilized for 4 weeks; others will allow active wrist flexion and extension (Figures 19-1C and 19-2C) only during the first 4 weeks, preventing supination or pronation and radial and ulnar deviation. At 4 weeks, the elbow portion of the splint is removed, keeping the wrist splint applied (Figure 19-25). The patient may then begin active supination and pronation exercises (Figure 19-5B and 19-6B) and continue with flexion and extension. At 8 weeks, splinting is usually discontinued and passive ROM exercises are started. Gentle strengthening begins between week 8 to week 10, with progression to weightbearing and plyometrics as tolerated (Figures 19-12 through 19-14, 19-23, and 19-24).

If the patient has been treated conservatively with a cast, once the cast is removed (at 6 to 8 weeks), begin active ROM for 1 to 2 weeks, with progression to passive ROM, then strengthening. Many surgeons prefer to have active ROM close to normal before beginning strengthening.

Criteria for Return

Return to sport with this injury, like many others, is dependent upon sport, position played, and ability to play in a splint or cast. As a general rule, the patient may begin conditioning activities (such as running) at 2 weeks, when the sutures are removed and the arm is placed in a long arm splint. At 8 weeks, he or she may begin weight lifting with the wrist taped for support. An athlete who plays a sport requiring stick work may begin stick skills at 10 weeks if this does not make the wrist more painful. Return to full activity usually occurs about 3 months after surgical repair, when the ligament is healed, the wrist is pain-free, and full ROM and strength have returned.

Scaphoid Fracture

Pathomechanics

Fractures of the scaphoid account for 60% of all carpal injuries.¹⁷ The prognosis is related to the site of the fracture, obliquity, displacement, and promptness of diagnosis and treatment.⁵² The blood supply of the scaphoid comes distal to proximal. Fracture through the waist of the proximal one-third of the scaphoid can result in delayed union or avascular necrosis secondary to poor blood supply. It can take 20 weeks for a proximal one-third fracture to heal, compared to 5 or 6 weeks at the scaphoid tuberosity.⁵² Displacement of the fracture occurs at the time of injury and must be treated early using ORIF.

Ninety percent of scaphoid fractures heal without complications if treated early and properly.³⁹ If the fracture does go on to nonunion, whether symptomatic or not, it should be treated. Not treating will lead to carpal instability and periscaphoid arthritis.²⁵ Diagnosis is made by X-ray. Patients will have wrist pain, especially in the anatomic snuffbox (Figure 19-28).

Injury Mechanism

Scaphoid fractures result from a fall on an outstretched hand. The radial styloid may impact against the scaphoid waist, causing a fracture.³⁹ The scaphoid fails in extension when the palmar surface experiences an excessive bending movement.⁵² Because the scaphoid blocks wrist extension, it is at risk for injury.⁴⁹

Rehabilitation Concerns

Of primary concern is proper diagnosis. If the patient has a history of a fall on an outstretched hand and has pain with thumb movement and tenderness in the anatomic snuffbox, but the initial X-ray is negative, they should be treated conservatively in a thumb spica cast for 2 weeks, then be X-rayed again.⁴⁹ If the X-ray is negative after 2 weeks, the cast may be removed and ROM begun. Another concern is scaphoid nonunions that can lead to carpal instability or periscaphoid arthritis. ROM of noninjured and noncasted joints must be maintained during prolonged periods of immobilization.

Rehabilitation Progression

Treatment of the nondisplaced scaphoid is casting. Following casting, an additional 2 to 4 weeks of splinting (Figure 19-29) may be used, with the splint removed for the exercise program. Active ROM exercises of wrist flexion, wrist extension (with finger flexion to isolate wrist extensors), and radial and ulnar deviation are initiated following immobilization (Figures 19-1 through 19-4). Thumb flexion and extension, abduction and adduction, and opposition to each finger are also initiated (Figures 19-7 through 19-9). After about 2 weeks (sooner if cleared by the physician), passive ROM to the same motion is begun. Gentle strengthening with weights or putty may be started around the same time. Strengthening is progressed over the next several weeks to include weight-bearing activities, plyometrics, and general arm conditioning to return to sport-specific activity (Figures 19-12 through 19-14, 19-23, and 19-24).

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Maintaining Cardiorespiratory Fitness During Rehabilitation Restoring Range of Motion and Improving Flexibility Regaining Muscular Strength, Endurance, and Power Rehabilitation of Elbow Injuries Rehabilitation of Injuries to the Spine Rehabilitation of Ankle and Foot Injuries

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