This document provides an overview of management approaches for various wrist and hand conditions, including carpal tunnel syndrome, trigger finger, De Quervain's disease, Dupuytren's contracture, mallet finger, flexor and extensor tendon injuries, complex regional pain syndrome, and peripheral nerve injuries. Non-operative and post-operative care is outlined for carpal tunnel syndrome, focusing on splinting, exercises to improve mobility, muscle performance, and dexterity. Other conditions are managed with modalities like ultrasound, splinting, stretching, strengthening exercises, and education on activity modification depending on the acute versus recovery phases.

1. Wrist and Hand
Management
By Rutuja Butala
(Musculoskeletal physiotherapist)

2. Carpal Tunnel Syndrome
1. Non operative management
• Ultrasound
• Nerve protection – rest & splinting
• Activity modification and education
• Mobility-
• Joint mobilization
• Tendon gliding exercises
• Median nerve mobilization
• Muscle performance:
Gentle multiple angle muscle setting exercises
Strengthening and endurance exercises
Fine finger dexterity- exercises with small objects using tip to tip, pad to pad and tip to pad
prehension patterns

3. Tendon gliding exercises Median nerve glide

4. 2. Post operative management
• Maximum protection phase-
Patient education
Wound management, control of edema and pain
Active tendon gliding and nerve gliding
Exercises-Active finger and thumb movements with wrist stabilized in neutral, active wrist
extension, active RD and UD, elbow and shoulder ROM.
• Moderate and Minimum protection phase-
Scar tissue mobilization
Stretching and joint mobilization
Muscle performance- begin isometric strengthening exes 4 wks after surgery, progress to grip and
pinch by 6 wks
Dexterity exercises
Sensory stimulation and sensory reeducation

5. Trigger Finger
• Patient education- Rest, modification of activities, splinting, etc
• Modalities- paraffin wax bath, ultrasound
• Exercises-
Digit blocking- patient blocks the MCP joint and allows the PIP
joints to bend. This exercise could be done with all fingers
simultaneously or individually
Tendon gliding exercises
Active range of motion- finger abduction, adduction

6. De quervain disease
• Immobilization- A thumb spica is used to restrict thumb movement so
that the first dorsal compartment tendons are at rest
• Cryotherapy- For 10 to 12 mins over the inflamed area
• Ultrasound- Pulsed mode, 3Mhz , 5 mins
• Phonophoresis- with 10% hydrocortisone
• Gentle active and passive motion of thumb and wrist encouraged for 5
mins every hour to prevent joint contractures
• Strengthening and stretching exercises after the initial pain subsides
Wrist stretch
Wrist flexion extension with weight
Wrist radial deviation and ulnar deviation with weights
Grip strengthening

7. Dupuytrens contracture
• Conservative management-
• Ultrasound
• Warm compress (early stage of the disease)
• Brace/splint to stretch the digits
• Range of motion exs to prevent adhesions
• Tendon gliding exs
• Post operative management-
• Within the initial 5 days postoperative, the primary interventions are to
educate the patient on decreasing edema and the importance of performing a
range of motion exercises on the uninvolved fingers.
• After 5-7 days postoperative, the primary interventions shift to a range of
motion exercises and splinting.

9. Mallet Finger
• Immobilisation phase-
• Splinting or pop cast
• Mobility of MCP and PIP joints with the splint
• Elevation for oedema control
• Mobilisation phase-
• Paraffin wax bath to improve Rom
• Active movements of the DIP joint
• Strengthening and reeducation of extensor digitorum communis is achieved by
using electrical stimulation
• Lumbrical strengthening
• Splint is continued till full extension at the DIP joint is regained
• Full function should return by 3-4 weeks

10. Jersey Finger

11. Flexor tendon injuries
• The tendons that can be involved include: flexor pollicis longus, flexor
digitorum profundus, flexor digitorum superficialis, flexor carpi ulnaris,
flexor carpi radialis.
• Flexor tendon zones:
• Zone I - distal to the flexor digitorum superficialis (FDS)
• Zone II - from the FDS insertion to distal portion of the A1 pulley
• Zone III - from the A1 pulley to the transverse carpal ligament
• Zone IV - the carpal tunnel
• Zone V - proximal to carpal tunnel
• The thumb has its own zone distrubution:
• Zone I - distal to the interphalangeal joint (IP) in the thumb
• Zone II - between the metacarpophalangeal (MCP) and interphalangeal (IP) joints
• Zone III - proximal to the metacarpophalangeal (MCP) volar/palmar flexion crease

12. • Flexor tendon sheath has 5 Annular and 3 cruciate pullies-
• A2 and A4 are most imp to prevent bow stringing of the tendons
• The annular pulley system's function is to keep the tendons close to the bone,
so that tendons don't bowstring in active flexion
• The cruciform pulley system is flexible and collapsible to allow for digital
flexion without deformation of the pulley system
• Mechanism of injury- commonly from volar/palmar lacerations or
rupture or tendon from its insertion
• Clinical presentation-
• Loss of active flexion strength or motion of the involved digit
• Pain when attempting to flex the involved digit
• Swelling
• Tenderness

14. Management

16. Extensor tendon injuries
• Extensor tendon injury is a cut or tear to one of the extensor tendons
• Extensor zones of the hand

17. • Mechanism of injury- Open wounds- direct lacerations by sharp objects, knifes or
scissors, saw injuries, blunt trauma, crush injuries
• Closed rupture- due rheumatoid arthritis, under extreme loads

18. Management- Zone 1 and 2

19. Management- Zone 4, 5 and 6

20. Management- zone 7 & 8

21. CRPS
1. Short Term Goals-
• Patient Education
• Explain nature of treatment & its benefits
• Explain scope of recovery
• Explain importance of exercises and home program
• If swelling, advice elevation
• To reduce pain
• Stage I: cold therapy- immersion – mixture of water and ice- 1:1 ratio-10mins.
• Modalities: IFT, TENS
• To control Edema
• Ice massage
• Elevation
• Pumping

22. • To improve mobility
• Stage I : gentle active exercises
• Movement of the part frequently throughout the day
• Tendon gliding exercises
• Stage II & III : joint mobilization, neuromobilization, stretching
• Desensitization
• Sensitization using different textures
• Brief periods- 5times/day
• Tapping/vibrations over the sensitive area
• Advice patient to wear a protective glove during activities of daily living.

23. • To improve muscle performance
• Stage I
• Facilitate active muscle contractions-proximal joints
• Static and dynamic exercises
• Alternating stress loading (compressive loading)with distraction for neuromuscular control as well
as afferent fiber stimulation
• Upper Extremity : stress load UE by scrubbing with a brush in quadruped position-3mins-
increasing to 10mins 3times/day
• Distraction –carrying 1-5pounds -10mins at a time
• Stage II & III
• Exercises to improve strength, endurance and overall functional performance meeting needs of the
patient

24. Long term Goals
• To improve Mobility
• To Improve Muscle performance
• To improve total body output
• Low impact aerobic exercises

25. Peripheral Nerve Injuries
• Acute Phase-
Patient education- Protection of the part, use of gloves
Immobilization- Time dictated by surgeon
Range of motion- Rom to minimize joint, and connective tissue contracture and
adhesions
Splinting- To prevent deformity, eg use of radial nerve splint to prevent wrist drop;
a median nerve splint to position the thumb in opposition

26. • Recovery Phase-Begins after signs of reinnervation
Motor retraining-
• Use of electrical stimulation to reinforce muscle action
• Progress from gravity elimination, active assisted rom to active Rom and resisted
rom
Desensitization-
• Use of multiple types of textures or contact for sensory stimulation, such as
cotton, rough material, sandpaper of various grades, and Velcro
• Use vibration: for hypersensitivity, perception of slow vibration, moving touch,
constant touch, rapid vibration and awareness from proximal to distal

27. Discriminative sensory re education-
• Begin by use of moving touch stimulus and stroke over the area
• Progress from stroking to constant touch
• Ask the patient to localize the touch
• Progress to identification of constant touch
• Ask to identify the objects

28. References-
• Clinical orthopaedic rehabilitation – s. Brent Brotzman, 3rd edition
• Therapeutic exercises- 6th edition, Kisner, Colby
• Orthopaedics and applied physiotherapy, Jayant Joshi, Prakash Kotwal, 3rd edition
• Physiopedia