Therapist`s Management of Fractures of the Hand

Therapist’s Management of
Mallet injury, Jersey Finger,
Pseudo-boutonniere, and Skier’s
Thumb
Julia Guthart, OTR/L CHT
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Mallet injury
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Therapist’s care of Mallet Injury:
• Non-operative:
Splinting
• Surgical:
– Closed reduction
percutaneous pinning
(CRPP)
– Splinting
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Non-Surgical: Splinting
• Pre-fabricated
• Stack splint
• Alumifoam
• Custom
• T-shape
• L-shape
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Custom Mallet splints:
T-shape
L-shape
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Mallet showing slight
hyperextension at DIP
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Use coban to secure
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Check PIP joint flexion
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L shape pattern
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Check PIP joint flexion
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Treatment
• Instruction in support of DIP Joint at all times
– While splint is off must hold DIP joint in extension
– i.e. with other hand, with thumb, with table top
• Attend therapy for weekly “splint checks”
• Or attend therapy for splint adjustments PRN
• Make sure PIP joint has full flexion; if lacking
full PIP motion, need therapy more often
• After 6 weeks, wear splint at night only
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After 6weeks
• If droop is reduced, can begin AROM
• No passive flexion of DIP joint
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Post-Surgical Care of Mallet Fracture
• Splint to support DIP joint
• Splint must protect pin
• Active and Passive ROM to PIP joint and MCP
joint
• Splint can be removed for exercises
• Instruct in Pin Care; provide pin care
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After Pin Removed
• ROM exercises
• Desensitization of fingertip
• A mallet splint/DIP gutter splint is fabricated
for night time wear and between exercise
sessions.
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Goals of therapy
• Full extension at DIP joint; extensor lag less
that 10 degrees is acceptable
• Gradual DIP joint flexion
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Complications
• Individuals with laxity at PIP, or
hyperextension, may need extra splint at PIP
joint to help balance extensor mechanism
• Pin track infection
• Non-compliance; MUST ALWAYS KEEP DIP
JOINT EXTENDED FOR SIX WEEKS
• Late-treatment, after sports season is over
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Jersey Finger
• Also known as Flexor Digitorum Profundus
rupture with avulsion fracture
• Treated as flexor tendon repair
• Has “button” or stitch through fingernail
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Therapy for Jersey Finger
• Begin therapy post-op day three
• Remove bulky dressing; re-dress with lighter
dressing
• Fabricate Dorsal Block Splint
• Passive controlled motion program or a
modified Duran program
• Wound care and edema care
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Jersey Finger Post-op Day 3
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3 days s/p to 3 ½ weeks
• PROM exercises are continued
• Scar pad fabricated or applied when sutures
removed and scar line dry
• Keep edema under control
• Can add active flexion and extension within
the DBS (splint) at 3 ½ weeks if approved by
surgical repair
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Dorsal Block Splint
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4 weeks
• Add ultrasound if necessary
• Add NMES (after active flexion exercises for 35 days) if re-education necessary
• Add AROM out of splint; tendon gliding
exercises
• Follow protocol for remainder of weeks
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Complications
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•
•
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Scar tissue impedes tendon excursion
Rupture
Co-morbidity issues of poor healing
Patient non-compliance with splint wearing
and home passive exercises
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Pseudo-boutonniere
• Due to PIP joint injury
– Dislocation with hyperextension
– Central slip injury
– Volar plate injury
– Most commonly due to “jammed finger” left
undiagnosed
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Definition pseudo-boutonniere
• PIP joint flexion contracture with the DIP
positioned in extension
• The DIP joint is passively flexible with the PIP
joint extended
• In a true boutonniere the ORL is not flexible so
cannot passively flex the DIP joint
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Therapist’s treatment:
• AROM and PROM DIP joint
• AROM and Passive Extension PIP joint
• SPLINTING: dynamic and/or static progressive
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Splinting for PIP joint
• A dynamic splint for on/off during day
OR
• A static-progressive splint for on/off during
day
• A static extension splint for night time
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Dynamic PIP extension splints
• Pre-fabricated splints for PIP extension such as
the LMB or joint jack or reverse knucklebender
• Custom hand based PIP joint extension splint
with outrigger
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Static progressive PIP extension
splints
• Custom “PIP Keeper”
• Serial cylindrical casting
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Exercise splint
• Keeps PIP joint in extension while patient
flexes DIP joint
• Helps with blocking exercises
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Complications
• It is difficult to obtain end range PIP joint
extension
• PIP joint may appear “flexed” due to fusi-form
shape of edema
• Patient non- compliance with therapy and all
the splints and schedules
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Thumb: MP joint Ulnar Collateral
Ligament injuries or Skier’s thumb
• Incomplete rupture = sprain; therefore
splinted for 4 weeks
• Complete rupture with Stener’s lesion=
surgery with pinning of MP joint; without
avulsion fracture, internal anchor or suturing
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Thumb UCL sprain
• Hand based thumb spica; IP free or included
depending on age of patient and lifestyle i.e. if
student or athlete, hand based thumb spica to
the tip with patient removing splint for IP joint
flex/ext only
• Will need to assess fit of splint and possibly
remold splint due to edema loss
• No therapy to MP joint for 4 weeks
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Thumb UCL repairs
• Pin to secure rupture of avulsion fracture OR
internal anchor
• Custom splint fabricated at 10 to 14 days after
surgery
• Thumb spica forearm based; if a pin is
present, therapist must bi-valve the splint for
on/off
• IP joint is free
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Therapy for Thumb MP joint UCL
• At 4 weeks can start AROM of MP joint; avoid
stress to UCL (such as stretching open thumb
web space activities)
• At 6 weeks can start AAROM of MP joint; at 7
weeks can add PROM to MP joint
• Avoid weighted resistence or sustained power
pinch until 14 -16 weeks
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Complications
• Pin track infection
• Scar adhesions decreasing web space
• MP joint extension lag is sometimes common
at first
• Patient non-compliance with splint wear, pin
care, return to sports
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Splinting Lab
• Mallet splint
• Dorsal gutter to PIP joint
• Night time extension gutter
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Other splinting slides
• Just for fun!
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Articular fracture with external fixator
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Articular fracture with external fixator
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Hand based safe position with bumper
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Hand based safe position with bumper
Two-piece splint held with velcro
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P2 fracture with pins: gutter splint
with birdcage
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P2 fracture with pins: gutter splint
with birdcage
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P1 fracture with ORIF
s/p day two
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Hand based Ulnar gutter
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Hand based Ulnar gutter
Small finger DIP free
Ring finger PIP free
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Multiple fractures
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Questions/Discussion
Contact information:
jguthart@joionline.net
Phone: 858-7045
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