A 66-year-old, right-hand-dominant, retired female teacher presents with a progressive history of right hand stiffness and pain. These symptoms have progressed to the point that she finds it difficult to manipulate fine objects and to tend to such activities as buttoning shirts and typing on a computer. These symptoms have developed over a 5-year period. She has been diagnosed with index, long, and small finger degenerative osteoarthritis of the proximal interphalangeal (PIP) joints (▶Fig. 51.1). Her symptoms were refractory to nonoperative management including nonsteroidal anti-inflammatory drugs, hand therapy, and resulting orthosis. At the time of presentation, the patient’s range of motion at the PIP joints was as follows: index finger 20 to 45 degrees; long finger 25 to 50 degrees; and small finger 20 to 60 degrees.
She had full and unrestricted range of motion of the metacarpophalangeal joints (MCP) of the right hand. Ultimately, the patient underwent surface replacement arthroplasty of the index, long, and small finger PIP joints (▶Fig. 51.2).
Rehabilitation was started at 5 days postoperative and consisted of a volar-based splint, which allowed for progressive, controlled PIP flexion as follows: 0 to 30 degrees of flexion from week 0 to 2; 0 to 60 degrees of flexion from week 2 to 4; and unrestricted PIP joint flexion thereafter. The patient’s postoperative course was slow and although she was compliant with orthosis wear, she was reluctant to flex her fingers at the PIP joints due to fear of “rupturing the implants.”
At 3 months postoperative, she complained of ongoing stiffness and swelling of the right hand. The patient’s PIP joint range of motion improved from the preoperative range of motion: index finger 20 to 65 degrees; long finger 15 to 80 degrees; and small finger 20 to 80 degrees. Her MCP motion, however, was restricted and measured 0 to 60 degrees for the index, long, ring, and small fingers. With hyperextension of the MCP joints of the index, long, and small fingers, the PIP joint flexion was only 40 degrees of each digit. With maximum flexion of each of the MCP joints, the PIP flexion could be restored to the following: index finger 65 degrees; long finger 80 degrees; and small finger 80 degrees. This finding was indicative of intrinsic tightness or stiffness of the right hand. This test is known as the Bunnell intrinsic tightness test (▶Fig. 51.3).
The patient should start with hand therapy, to include intrinsic stretching of each of the affected digits, MCP extension block orthosis to provide active intrinsic stretching during activities of daily living (▶Fig. 51.4), anti-edema exercise to include overhead fisting maneuverers of the right hand as feasible by the patient, and an anti-edema glove for the right hand to be worn 8 hours per day. The patient should also be given a Medrol dose pack (Solu-Medrol 8 mg, 6 mg, 4 mg, and 2 mg given over a 4-day period).