Hand Therapy

What are the different assessment factors to consider?

• Age

• Gender

• Occupation

• Condition

• Other pathology

• Emotional and motivation

• Cognitive ability

• Socio-economic condition

• Social support

What are the possible complications in hand injuries?

• Bone deformities (malunions)

• Delated union and non-union fractures

• Bone infection (osteomyelitis)

• Nerve or blood vessel damage

• Osteoarthritis

What are the different precautions in hand evaluation?

• Open wounds

• Stage of wound healing

• Sensations

• Oedema

What is typically included in a hand assessment?

• Hand dominance

• Age

• Work

• ROM

• Sensation

• Dexterity

• Functional use

• Oedema

• Scar assessment

• ADL and IADL

What are the different upper limb standardised assessments?

• Nine-Hole Peg Test

• Box and Block Test

• Jebsen-Taylor Hand Function Test

• Smith Hand Function Test

• Purdue Pegboard

• Minnesota Manual Dexterity Test

• Disabilities of the Arm, Shoulder and Hand (DASH)

• Semmes-Weinstein Monofilament Test

• Jamar Dynamometer and Pinchometer

What are the treatment modalities for oedema?

• Elevation

• Active range of motion

• Contrast baths

• Compression

• Pressure garments

• Manual oedema massage

What are the stages of wound healing and the intervention at each stage?

• Acute inflammatory phase (0-6 days)

  • Rest/immobilise

  • No stress

• Fibroplasia phase (5-36 days)

  • Mobilisation by applying light stress

  • Monitor effect of splint on swelling, pain and colour changes

• Scar maturation phase (4 weeks - 2 years)

  • Mobilisation by applying more stress over a long period

  • Splints are designed to influence the remodelling of collagen and ensure the recovery of articular gliding and excursion

• Wound contracture

  • Resist contractile forces even 6 months and excursion

  • Provide long-term splinting

What is the rationale for splints?

• Pain relief

• Support/position

• Protection/immobilisation

• Prevention/correction of deformity

• Oedema control

• Maintenance/restoration of ROM

• Scar remodelling

What factors should be considered when making a splint?

• Individual patient factors

• Length of time splint will be used

• Simplicity and cosmesis

• Optimum sensation

• Optimum function of the extremity

• Efficient construction and fit

• Easy application and removal

• Splint exercise regime

• Exact disease, injury or deformity

• Goal of splinting regime

• Most effective way to reach goal

• Anatomic and material variables

What actions should be completed while making the splint?

• Identify key joints

• Revise purpose of the splint

• Kinetic effect

• Surface of splint application

• Static or dynamic force

• Use mechanical principles advantageously

• Adapt for anatomic variables

What are the types of arthritis?

• Osteoarthritis (OA): A degenerative joint disease characterised by the breakdown of articular cartilage, causing pain, stiffness and reduced joint function.

• Rheumatoid arthritis (RA): A chronic autoimmune inflammatory disease in which the immune system attacks the synovial lining of joints, causing inflammation and progressive joint damage.

In which site does osteoarthritis develop?

• 1st CMC joint

• DIP joints

• PIP joints

What is the osteoarthritis quintet?

• Heberden’s nodules

• Mucoid cysts

• OA of the 1st CMC joint

• Trigger finger

• Carpal tunnel syndrome

What is the initial treatment for OA?

• Splinting

  • Improve stability

  • Prevent deformities

  • Decrease pain and improve function

  • Worn during the day only (night if pain)

• Surgery: Excision arthroplasty/silastic joint replacement

  • If no improvement

What is the post-surgical treatment for OA?

• POP splint

  • 4-6 weeks

• Scar and soft tissue massage

• Gentle active and passive movement

• Graded strengthening exercises

What is the treatment for OA of the DIP joints?

• Arthrodesis of involved joints

• K-wire fixation for 6 weeks

• Protective splinting (from 10 days post operation)

• Finger socks

• Scar massage

• Gentle active and passive motion of PIP and MP joints

• Flexion against light sponge; putty exercises

What is the clinical picture of RA?

• Wrist: Gradual radial deviation

• MP joints: Gradual volar subluxation and ulnar deviation

• PIP joints: Swan neck or Boutonniere deformity

• Thumb: Boutonniere deformity

What is the treatment for RA?

• Surgery: Synovectomy of the wrist

What are the types of brachial plexus injuries?

• Neuropraxia (stretch)

• Rupture

• Avulsion

What are the brachial plexus nerves?

• Axillary

• Median

• Musculocutaneous

• Radial

• Ulnar

What is the acute phase treatment for brachial plexus injuries?

• Positioning

• Splinting

• Gentle exercises

What is the post-operative phase treatment for brachial plexus injuries?

• Sling

  • 4-6 weeks

• One-handed technique education

• Hand splint

• Early passive mobility of distal joints

What is the rehabilitation phase treatment for brachial plexus injuries?

• Roles

• Work

• Interests/hobbies

What is the general treatment for brachial plexus injuries?

• Pain management

• Splinting

• ADL and IADL

• Dexterity

• Fine motor coordination

• Hand-eye coordination

• Strengthening

  • Exercises

  • Slings

  • Strengthening band

  • Putty

• Sensory re-education

• Assistive devices

• Emotional and social factors

• Patient education

• Vocational rehabilitation

• Hobbies and leisure

What is the treatment for neonatal brachial plexus palsy?

• Passive movements

• Sensory stimulation

• Bilateral hand use

• Possible wrist extension splint

• Home programme:

  • ROM

  • Speed

  • Functional capacity

  • Mobility

  • Hand manipulation skills

What are levels of the Highest Scale for motor function?

• M0: No contraction

• M1: Trace of contractibility

• M2: Joint motion, gravity eliminated

• M3: Joint motion against gravity

• M4: Joint motion with some resistance

• M5: Joint motion with full resistance

What are levels of the Highest Scale for sensory function?

• S0: No sensation

• S1: Deep pain sensibility

• S2: Some superficial sensibility, paraesthesia and pain

• S3: Superficial sensibility, disappearance of paraesthesia and return of sweat

• S3+: 2-point discirmination less than 12mm. Light touch near normal. Full use of hand.

• S4: Normal sensibility.

What are the types of peripheral nerve injuries?

• Neuropraxia

• Axonotmesis

• Neurotmesis

What factors affect the outcome of nerve repair?

• Age

• Mechanism of injury

• Location of injury

• Types of nerve

• Associated injuries

• Nerve gap size

• Tension at repair site

• Technique of repair

• Timing of repair

What are the tests for nerve damage?

• Tinel’s sign

• Wrinkle test

• Semmes and Weinstein Monofilament Test

• Two-point discrimination test

• Muscle strength

What does a proximal median nerve injury result in?

• Weaker PIP and MP flexion

• Absent DIP and PIP flexion of index and middle finger

• Pronation with gravity

• Sensation loss

What does a distal median nerve injury result in?

• Loss of intrinsic thumb function

• Sensation loss

What is the treatment for a median nerve injury?

• Surgery (neurotmesis)

• Maintain ROM

• Education

• Splinting (preventative, functional)

• Sensory and motor retraining

What does a distal radial nerve injury result in?

• Triceps intact

• No wrist extension

• No finger extension

• No thumb extension

• Sensory loss

What is the treatment for a radial nerve injury?

Splinting:

• Forearm-based static wrist extension splint

• Forearm-based dynamic finger extension splint

Post-tendon transfer:

• Immobilisation in cast

• Shoulder motion retained

• IP flexion/extension

• Replace cast with thermoplastic splint

• Individual joint mobilisation

• Retrain function

What does a proximal ulnar nerve injury result in?

What does a distal ulnar nerve injury result in?

What is the treatment for an ulnar nerve injury?

Early:

• Suture after diagnosis

• Immobilisation in POP cast

• Restrictive splint

• Function and grasp

• Sensory re-education

Post-reconstruction:

• Immobilisation in POP

• MP extension restriction splint

• Scar management

• Retraining of grasp

• De-sensitisation

What are the methods for assessing oedema?

• Water displacement: Volumeter

• Circumferential figure-of-eight measurement: Tape measure

What are the treatment modalities for oedema?

• Elevation

• Exercise (AROM)

• Massage

• Compression

• Contrast baths

• Coban wrapping

• Manual oedema mobilisation

• Brazilian hand wrap

What are the causes of stiffness?

• Joint tightness

• Muscle tightness (instrinsic)

• Muscle-tendon tightness (extrinsic)

• Skin tightness

What are the treatment modalities for a stiff hand?

• Splinting

• Massage and heat

  • Heat pack

  • Wax bath

• Passive stretching

• Passive joint mobilisation

• Scar management

• Activities

What are the types of splints used to reduce stiffness?

• Serial static splint (POP)

• Dynamic splint

• Static progressive splint

What is total end range time (TERT)?

The total time a joint is maintained at end range for.

What is daily end range time (DERT)?

The total time per day a joint is maintained at end range for.

What is the initial treatment for a severely injured hand?

• Provide wound care

• Rest (splinting/activity)

• Gentle mobilisation

• Manage oedema

• Exercise, maintain joint mobility and prevent tendon gliding

• Mobilise uninvolved joints

• Consider psycho-social needs

What is the rehabilitative treatment for a compartment syndrome?

• Splinting to maintain full extension

• Scar massage

• Gentle active and passive movements

• Pressure garment to manage oedema

• Functional use of hand

What is the intermediate phase treatment for a severely injured hand?

• Static splint

• Dynamic splint

• Activities and exercise

• Skin cover and scar management

• Desensitisation

• Skills retratining

• Simple domestic activities

• Psychological aspects

• Patient education and supppport

• Oedema control

• Wound and pain management

• AROM and PRO

What is the late phase treatment for a severely injured hand?

• Exercise, strengthening activities

• Work rehabilitation

What are the extrinsic flexor muscles?

• Flexor digitorum profundus (FDP)

• Flexor digitorum superficialis (FDS)

• Flexor pollicis longus (FPL)

How is the action of FDP tested?

Action: DIP flexion

How is the action of FDS tested?

Action: PIP flexion

How is the action of FPL tested?

Action: IP flexion of thumb

What are the wrist flexor muscles?

• Flexor carpi ulnaris (FCU)

• Flexor carpi radialis (FCR)

What are the flexor tendon zones?

What is the common injury in flexor zone 1?

Jersey finger: Avulsion of FDP

What is the post-operative splinting for a flexor tendon injury?

• Dorsal blocking splint

  • Forearm-based

  • Wrist in 20-30° flexion

  • MPs in 60° flexion

What is the protocol during phase 1 (0-4 weeks) following a flexor tendon repair?

• Immbolisation

  • POP and thermoplastic splint

  • Least used protocol

• Early passive mobilisation

  • Non-removable POP splint with dynamic traction

    • Wrist in 20-30° flexion

    • MCP in 70-80° flexion

    • IP in extension

  • Maintain flexion, allow extension

  • Most frequently used

• Early active mobilisation

  • Removable thermoplastic splint

Which factors influence the protocol chosen following a flexor tendon repair?

• Age

• Zones injured

• Quality of surgery

• Patient’s residence

• Comprehension and compliance

• Time of OT referral

What are the splinting guidelines for early passive mobilisation following a flexor tendon repair?

• Dorsal blocking splint

• Elastic bands unattached at night and for alternating periods during the day

• Crepe bandage wrapped lightly around splint

• Active extension of fingers as far as allowed by splint

• Maintain extension position for 5 seconds

• Repeat 10 times every waking hour

What are the splinting guidelines for early active mobilisation following a flexor tendon repair?

• Dorsal blocking splint

  • Strip on palmar aspect

• Passive flexion of fingers

• Maintain flexion position for 5 seconds

• Repeat 10 times every waking hour

• Fingers strapped into extension every other hour

• Gentle active flexion after 2 weeks

• Active place and hold:

  • Passive MP extension and wrist extension

  • Passive wrist flexion and MP + IP extension

What is the protocol during phase 2 (5-6 weeks) following a flexor tendon repair?

Week 5:

• Splint removed for exercises

• Scar massage commences

• Active finger movement without resistance

• Activities performed in soapy water

• Splint remolded with more extension

  • Remove 3-4 times a day to mobilise and wash hand

  • Rubber traction removed

• Paraffin wax and ultrasound

• Finger socks and pressure gloves

• Squeeze sponge in water

Week 6:

• Adapted table games to encourage IP flexion (clamps)

• Block joints proximally and flex fingers

• Light to medium theraputic putty

What is the protocol during phase 3 (7-12 weeks) following a flexor tendon repair?

Week 11:

• Dorsal blocking splint worn at night

• Dynamic dorsal finger extension splint during day and night

• Return to light duty

• Therapy 1-2 times per week

• Activities against resistance and requiring static grips

• Scar management

Week 12:

• Resume normal activities

• No contact sport for another 4 weeks

What are the treatment modalities for a flexor tendon repair?

• Passive motion (up to week 5)

• Active motion (from 4 weeks)

• Functional activities (after 6 weeks)

• Therapeutic equipment

• Manual oedema mobilisation

• TENS

• Splints

  • Post-operative flexor tendon POP

  • Dorsal extension blocking splint

What is the tendon glide exercise used for a flexor tendon repair?

Which assessments are used for a flexor tendon injury?

• General observations

• Oedema

• ROM (from 6 weeks)

• Muscle strength (from 8 weeks)

• Sensation

• Hand function (from 6-8 weeks)

• Grasps (from 6-8 weeks)

What are the extensor tendon zones?

What are the extensor muscles?

• Extensor digitorum communis (EDC)

• Extensor pollicis longus (EPL)

What is the action of EDC?

• Extend MP joints of medial 4 fingers

• Assists in IP extension

What is the action of EPL?

• Extends all joints of thumb

• Assists in extension and abduction of wrist

What is the post-operative splinting for an extensor tendon injury in zone V-VII?

• Wrist in 30-40° extension

• MP in 30° flexion

• PIP in extension

• DIP free

What are the splinting protocols following extensor tendon repair?

• Dynamic splinting with early passive motion

• Static splinting with early active motion

What is the weekly protocol for dynamic splinting with early passive motion?

3-5 days:

• Forearm-based dorsal dynamic extension splint

  • Wrist in 40-45° extension

  • MP joint in 0°

  • Worn 24 hours

• Active MP joint flexion 10 times per waking hour

• Oedema control

• Scar management

• Wound care

• Splint adjustments

• Positioning

• Exercises (tenodesis)

2-4 weeks:

• Palmar block removed (week 3)

4-6 weeks:

• Traction removed (week 5)

• Active finger extension

• Extension against gravity

• Exercises

6-8 weeks:

• Splint removed

• Resistance training

• Full flexion at 8 weeks

What is the weekly protocol for static splinting with early active motion?

0-4 weeks:

• Static forearm-based palmar splint

  • Wrist in 40-45° extension

  • MPs in 20-30° flexion

  • Gentle strap over MPs

• Exercises

  • Passive MP extension

  • Active MP extension

4-6 weeks:

• Splint shortened to free MPs

• More MP flexion and tendon excursion

6-8 weeks:

• Splint removed

• Resistance training

• Full flexion at 8 weeks

What are the classifications of fractures?

• Acute

  • Simple or compound

  • Stable or unstable

  • Intra-articular

  • With associated injuries

• Chronic

  • Malunion

  • Non-union

  • With associated joint contractures

• Pathological

  • Colles fracture

What are the methods of stabilising fractures?

• Conservative

  • Static splinting

    • DIP extension splint

    • Burkhalter splint

  • Dynamic splinting

    • Buddy splint

• Surgical