Hand Therapy Management of Finger Injuries

Educational Objectives

The goal of this program is to improve management of injuries of the hand. After hearing and assimilating this program, the clinician will be better able to:

1. Prescribe a rehabilitation program for proximal interphalangeal joint injury, including range of motion exercises, strengthening exercises, and functional activities.
2. Select appropriate splint options for finger stiffness.

Summary

Introduction: the metacarpophalangeal joint (MCP), proximal interphalangeal joint (PIP), and distal interphalangeal joint (DIP) maintain a complementary relationship; injury at one joint may lead to dysfunction of the neighboring joints or digits; fibroblastic phase lasts for ≈3 wk; collagen is deposited in a disorganized manner, causing adhesions; inadequate or overzealous immobilization can be detrimental at this juncture

PIP injury: the PIP joint adopts a flexed position after injury; soft tissue contracture may lead to a permanent flexion deformity; even minor injuries to the capsule or ligaments should be immobilized for ≤3 wk in full extension; a 5-mm increase in flexor and extensor tendon glide equates to a gain of 0 to 40 degrees of PIP joint motion; early mobilization is essential to prevent tendon scarring and improve joint range of motion (ROM); volar PIP joint dislocations often result in central slip injury and a boutonniere deformity; dorsal dislocations may lead to volar plate contracture and a pseudo-boutonniere deformity

Examination: a comprehensive hand examination includes identifying the injury site and assessing deformities, wounds, tendon function, and neurovascular status; the therapist must evaluate active and passive ROM, hypersensitivity, edema, and joint laxity; if the unaffected joint is already stiff and stable, it might be challenging to achieve significant improvement in the injured joint; if the unaffected joint is more flexible, eg, mallet finger, a 2-step orthosis may be considered

Source of stiffness: to identify the source of stiffness, the therapist needs to assess the specific structures involved; radiography may help identify articular issues; if active and passive ROM are equal, the stiffness is likely caused by intraarticular pathology, capsular ligament fibrosis or issues with musculotendinous units, including extensive movement of flexor tendons (FTs), intrinsic contributions, and tenosynovitis; if passive range exceeds active range, the issue may be musculotendinous unit disruption, subluxation, or adhesions; limited active flexion in the presence of full passive joint flexion suggests FT injury or adhesions of the FT; decreased passive finger extension is suggestive of shortening or adhesion of the extrinsic flexor muscle tendon; the Bunnell test helps identify intrinsic muscle tightness in cases of extension contractures; this test is positive when there is less PIP joint flexion with MCP extension, compared with MCP joint inflection; soft tissue structures should be assessed for abnormalities or limitations in their mobility and compliance

Management: compression wraps — eg, Coban, Philipose sleeves, Demis sleeves; used to reduce swelling; apply the compression wraps lightly to avoid circulation issues; recommended usage is to wear during the day, remove for a few hours, then apply a looser compression at night; massage and exercise — patients may be taught to perform self-massage techniques to help reduce swelling and promote tissue healing; active ROM exercises are important for removal of excess fluid and organizing scar tissue; these exercises should be performed frequently, every 1 to 2 hr, for short durations; instrument-assisted soft tissue techniques — work at a deeper tissue level to resolve adhesions and prevent tendon excursion or joint movement; scar conformers — the postoperative use of splints (eg, AutoForm, EasyForm) helps reduce scarring and hypersensitivity; using silicone scar sheets (eg, Mederma) for a few hours daily may further improve scar appearance; other modalities include the use of direct current, wherein the negative polarity helps to reorganize fibrotic scar tissue and reduce inflammation; joint blocking exercises, protective splinting, and body taping can also be helpful; passive ROM exercises may help overcome joint stiffness but should be performed gently and comfortably; patient education and active participation are crucial for optimal outcomes

Joint mobilization: helps to improve motion in a stiff joint, minimize pain, restore joint kinematics, and correct positional faults that decrease ROM; reverse blocking exercises are crucial for strengthening the extensor mechanism, as flexion often recovers more naturally through performance of daily activities; extension is more difficult to achieve because of the thinner, flatter anatomy of the extensors and the propensity for flexure contractions; reverse blocking exercises should be performed frequently to strengthen the extensor mechanism; avoid overworking muscles, as this may lead to excessive fatigue and inflammation; use blocking exercises and putty for capsular stiffness

Extrinsic Extensor (EE) Tightness

Resolving EE tightness: requires composite stretching and deflection, followed by an active functional task, eg, wringing a washcloth or towel; weight-bearing exercises help stretch extrinsic flexor muscles and improve wrist extension; splints may be used to increase flexion and extension; static splints that block the MP joint can help improve PIP joint flexion by redirecting the force of finger flexion

Relative motion orthoses: becoming increasingly popular for treating finger contractures; they redirect forces to target specific joints and improve ROM; to increase PIP joint flexion, the MCP joint can be blocked, which forces reliance on the FTs to bend the PIP joint

Type of orthosis: modified Weeks test is used to determine the appropriate type of orthosis for a patient with finger stiffness; ROM is measured before and after a 10-min heat therapy session and some joint mobilizations; orthosis type is recommended based on ROM improvement; for 20-degree improvement, no orthosis is recommended (focus on active exercise and stretching); for 15-degree improvement, a serial static splint is recommended; a dynamic splint and static progressive splint are recommended for 10-degree and 5-degree improvement, respectively

Dynamic orthosis: uses elastic components to apply a constant force to a specific joint, promoting gradual tissue stretching and improving ROM; most effective in the early stages of healing

Serial elastic tensioning (SET): this orthosis uses a total end range time protocol and is worn in clinical and home settings; current literature suggests a maximum daily wear time of 12 hr for dynamic orthoses to treat PIP joint contractures

Neoprene splints: preferred over traditional splints because of their potential to reduce skin irritation, especially over the PIP joint; Punsola-Izard (2023) demonstrated the effectiveness of neoprene SET in treating a persistent PIP joint contracture

Static progressive orthoses: rely on the principles of stress, relaxation, loading or low load, and prolonged stretch; when tension is applied, the joint is positioned at its maximum in range; the force is adjusted when the tissue response allows repositioning to the new length; usually worn for shorter sessions several times per day (eg, 5-10 min 3 times/day, then increased to 2-3 times/day for 30 min)

Postsplint functional activity: patients should commit to 5 min of functional activity or exercise daily after removing the splint; this helps reestablish normal movement patterns in the motor cortex, encourages gliding and stretching of tendons and ligaments within the new ROM, promotes lasting improvements, and minimizes potential edema

Dorsal finger orthosis: a type of splint designed to mobilize the PIP joint into extension; functions like a ramp, gradually guiding the joint into a more extended position; the splint must be worn for 30 min

Serial casting: appropriate for chronic contractures <45 degrees with equal passive and active motion; cast can be changed 2 to 3 times in 1 wk; plaster of Paris or quick cast is used; for severe contractures >45 degrees, the tissues may not tolerate excessive force and amount of time needed to wear orthotics may result in skin breakdown; surgical intervention or external fixation system (eg, Digit Widget) may be useful

Considerations: active hook fist exercises to target intrinsic muscle tightness can be beneficial; joint mobilization distal to the restriction can help regain tendon glide

Outcomes: Weeks et al (1978) showed that therapy alone successfully treated 87% of PIP and MCP joint contractures; Flowers (2002) and Glasgow (2003) demonstrated that passive ROM is a function of increasing splint time and the force applied with the splint; optimal intensity and duration of therapy is not well defined; decision to pursue surgery is patient-dependent

Readings

Cahill KC, Theopold C, O'Shaughnessy M. Experiences with pins and rubber band traction in the treatment of proximal interphalangeal joint contracture. Plast Surg (Oakv). 2016;24(1):20-22. doi:10.4172/plastic-surgery.1000948; Flowers KR. A proposed decision hierarchy for splinting the stiff joint, with an emphasis on force application parameters. J Hand Ther. 2002 Apr-Jun;15(2):158-62. doi: 10.1053/hanthe.2002.v15.015015. PMID: 12086026; Freiberg A. Management of proximal interphalangeal joint injuries. Can J Plast Surg. 2007;15(4):199-203. doi:10.1177/229255030701500407; Glasgow C, Tooth LR, Fleming J, et al. Dynamic splinting for the stiff hand after trauma: Predictors of contracture resolution. J Hand Ther. 2011;24(3):195-206. doi:10.1016/j.jht.2011.03.001; Wang ED, Rahgozar P. The pathogenesis and treatment of the stiff finger. Clin Plast Surg. 2019;46(3):339-345. doi:10.1016/j.cps.2019.02.007; Weeks PM, Wray RC Jr, Kuxhaus M. The results of non-operative management of stiff joints in the hand. Plast Reconstr Surg. 1978;61(1):58-63. doi:10.1097/00006534-197801000-00010.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. O’Connell was recorded at the 1st Annual Cedars-Sinai Hand and Upper Extremity Symposium, held on December 9, 2023, in Los Angeles, CA, and presented by Cedars-Sinai. For more information about upcoming CME activities from this presenter, please visit cedars.cloud-cme.com/handorthocme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

OR480102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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