Hand therapy for common hand innjuries

1. Dan Purtell
Hand / Occupational
Therapist

2. Trigger finger / thumb
De Quervain’s
Mallet Finger
PIPJ Dislocations
Dupuytren’s disease
Simple #’s

3.  Not clearly /
consistently defined
 Triggering of the digital
flexor tendons at the
fibrooseous tunnel
formed by the
metacarpal neck and
A1 pulley
 In thumb the sesamoid
bones may also be site
of constriction
 Generally affects FDS
rather than FDP
because it lies directly
under A1 pulley

5.  Primary trigger
finger most
commonly found in
middle aged
women, 2–6 X more
than men
 Most commonly
affects thumb (30-
50%)
 Then ring, long,
index, & little

6.  Stenosing tendovaginitis
 Digital flexors susceptible to compression
and shear at level of wrist and MP joints
where they enter fibrooseous tunnels
 Blunt trauma or sustained tool use causing
direct compression at A1 pulley
 Secondary TF in individuals with connective
tissue disorders

7.  Discrepancy between
the size of the A1 finger
pulley lumen and
tendon volume
 Hypertrophy of the
pulley
 Poor tendon
vascularity between A1
and A2 pulley makes
tendons more
susceptible to
degenerative changes
 Tendons develop
nodules from
tenosynovitis

8.  Pain over site of tendon disorder aggravated
by movement
 Symptoms vary from stiffness, to uneven
movement, catching, blocking, or complete
locking of tendon
 Pain can also be referred to distal joint or
proximally up forearm
 Local swelling and thickening creating a
palpable nodule over distal palmar crease
(A1 pulley area)
 Local tenderness over A1
 Patient may present with acute, subacute or
chronic disorder

9. Patients often reluctant to
have cortico-steroid injection,
even more reluctant to have
surgery
Conservative measures should
be trialled for 4-6 weeks
 Thermoplastic hand based
splint to limit MCP flexion
(stops triggering through A1
pulley)
 Splinting works better for
fingers than for thumbs

10.  Trigger Thumb -
Thermoplastic barrel
splint, IP joint at 10
degrees flexion
 Passive tendon gliding
exercises
 Soft tissue massage of
nodule and tendon.
 +/- Ultrasound
 +/- NSAID gel

11.  Cortisone injection
for trigger fingers
and thumbs relieves
symptoms in 47% to
94% of affected
digits.

12.  Most reported success rates are
above 90%.
 Decompression of pulley to
allow flexor tendon to glide
 Turowski, 1997: n=59, 97%
complete resolution. No post-op
nerve or tendon damage.
 Eastwood, 1992: Percutaneous
release, n=35, 94% complete
resolution. No complications.
Not for thumb
 Thorpe, 1988: n = 53, 60%
complete resolution, success
correlated with surgeon skill.

13.  Oedema and wound management
 Scar management once wound healed
 Active tendon gliding exercises
 Stretching long finger flexors
 Strengthening only if necessary
Conclusion
 Surgery remains the most successful treatment
option
 Splinting and exercise program good alternative for
those patients reluctant to consider a CSI or surgery

14.  de Quervain’s
tenosynovitis is
the entrapment
tendonitis/tenosy
novitis of the
abductor pollicis
longus and
extensor pollicis
brevis tendons at
the styloid
process of the
radius

15.  Most cases it is a
tendinopathy like
trigger finger,
tennis elbow etc
that leads to
tenosynovitis.

16.  Finklesteins test and clinical Hx confirm
diagnosis.

17.  10 x more Common in Women than men.
 Common in pre-post natal and menopause.
 Often caused by repetitive strain or
sustained posture of the wrist = strain on
EPB and APL.
 Can occur post direct trauma to the area
(rare)

18.  Treatment:
 Steroid (won’t fix
tendinopathy)
 Splint and rest
 Kinesio tape
 Surgery (last resort)

19.  Surgery

20.  Any injury that causes
a mallet deformity of
the distal phalangeal
joint

21.  Disruption of the terminal extensor tendon as it
inserts into distal phalanx +/- fracture

23. MECHANISM OF
INJURY
 Flexion force on
extended DIP joint
 Direct crush
 Ball to tip of finger
 Often occurs in
ball sports.

24. Signs & Symptoms
 Inability to extend
distal phalanx actively
 Can still passively
extend within pain
limits
 Swelling
 Bruising
 Redness

25. Volar plate laxity = swan
neck deformity

26.  depends on size of fragment and position of
joint
 If complete tendon rupture without
fracture
 If # is less than 30% joint surface
→ Conservative management -
splinting
 If # greater than 30% joint surface or joint is
significantly displaced needs surgical
intervention

27.  Mallet splint reduces the
fragment

28.  Splint DIP in hyperextension 6 – 8/52
 Splint strictly 24/24
 Clear instructions and demonstration re
changing and wearing routine
 Advice re skin care
 PIP flexion exercises
 May return to sport with
splinting

29.  Off the shelf stack
splint often fit
poorly
 Patient may end up
with a lag at DIP
joint

30.  Wean splint slowly after
6-8 weeks
 Keep on at night and for
work a further 2 weeks
 Initially active flexion
exercises to gain full
flexion
 Start off 30 degrees flexion
first week and increase
slowly ie 20 degrees per
week
 May take 4 – 6 weeks to
regain full flexion
 If lag reoccurs →
RESPLINT
 Passive flexion only
added if needed

31.  Large Fragment
 Fixed with K-wire or 2

33. - Conservative approach
only if small fragment with
no joint subluxation.
- Splint for 6/52 in barrel
splint
DIPJ can be free.
- Larger fragments with joint
subluxation can be ORIF’d.

34. = Boutonniere Deformity
= FFD of PIPJ
= Very hard to fix

36.  Mechanism of Injury – hyperextension of the
PIP joint
 with or without dislocation
 often initial injury seems trivial

37.  Dislocation of the
PIPJ
 Avulsion # of
middle phalanx
 Disruption of volar
plate over the PIP
joint

38. Signs & Symptoms
• Swelling
• Bruising
• Pain volar aspect of
PIP joint
• Instability or pain
on stress of volar
plate
• Decreased range of
motion particularly
flexion

39.  If dislocation without #
OR
If # fragment less than 30% joint
surface
→ reduce then manage
conservatively in dorsal
blocking splint (DBS)

40. Dorsal blocking splint
• PIPJ in 30 degrees
flexion
•volar structures
off
stretch
•slowly increase
out
to neutral

43.  splint 4 - 6/52
 weekly adjustments PIPJ from 30
flexion → full extension as stability
increases
• Coban for swelling
• Flexion exercises within splint
• Isolated FDP & FDS flexion important to
prevent adherance to volar plate
• Early mobilisation also assists oedema

44. • If collaterals involved need to buddy
strap when out of splint
• Tape/splint for work for 6 -8/52
• Watch for FFC PIPJ in late stages → may
need to include extension splinting

45.  If volar plate repaired post surgical
management same but progress
slower
 Occasionally flexion exercises are
delayed if stability is a concern

46.  5th Metacarpal
 Assess ROM and digit
Rotation
 Usually managed
conservatively

47.  4th Metacarpal Spiral #
 Assess ROM and digit
Rotation
 Tendency to rotate
 Impacted #’s result in
extension lag = poor
function.

48. Treat conservatively in splint
unless joint subluxation
occurring

49. Treat conservatively in splint
unless joint subluxation or
stenners lesion is present.
- Usually characterised by
lots of oedema, nil end point
of stability.
- Very difficult to assess with
certainty
- U/s scan to confirm