This document discusses the management of stiff hands. It begins by explaining the causes of stiff hands including pain, immobilization, and scar formation. It then describes the stages of wound healing and techniques used to address edema, joint stiffness, tissue adherence, and pathological motion patterns that can develop after injury. The document emphasizes the importance of early active motion to guide tissue remodeling while avoiding overloading healing structures. It provides details on various types of mobilization splints that can be used at different stages of healing to promote tissue adaptation through prolonged, low-load forces applied in the direction of the desired motion.

1. STIFF HAND
MANAGEMENT
Compiled by: Rashi Goel
Moderator: Anupama mam
4/6/2022 1

2. HOW??
• Flexible hand- stiff hand
4/6/2022 2
Pain
Immobilization
Scar formation

3. Stiff Hand
• Hand lacking full mobility
• Stiffness is- constraint created by cross- linking
the previously elastic configuration of the
collagen fibers
4/6/2022 3

4. 4/6/2022 4

5. Normal hand motion
Strong, dense
connective tissue glide
relative to one another
4/6/2022 5
Stiffness
Fixation of the tissue layers
cross- links binding collagen fibers
together
Usual elastic relational motion is
restricted

6. Stages of wound healing
1. Inflammatory- wound prepares to heal
2. Fibroplasia- tissue structure is rebuild
3. Remodeling- final tissue configuration
develops
4/6/2022 6

7. 1. Inflammatory stage
• Completed within a few days
• Mostly immobilized after surgery to rest the
wound
4/6/2022 7

8. 2. Fibroplastic stage
• Begins at end of 1st week
• 2 days later- collagen synthesis
• Fibroblasts more in no. than granulocytes and
macrophages
• Fiber synthesis 7 contraction of wound edges
• Capillaries reestablish within the wound, form
a dense network
• Scar not strong- so cannot tolerate excessive
stress
4/6/2022 8

9. • Joint stiffness & tissue adherence- soft end
feel
• As cross- linking of the collagen fibers is weak
• So excess force can tear the fibers, causing
more injury
• Ideal – Intermittent active motion to realign
4/6/2022 9

10. 3. Maturation stage
• Normal - between 3 – 6 weeks of injury
• In injury- cell population decreases, scar
collagen fibers increases
• Collagen deposition with collagen degradation,
creating equilibrium
• As scar matures- alteration in the architecture
of scar collagen fibers occurs due to canes in
the no. of covalent bonds between collagen
molecules
4/6/2022 10

11. • In early part- intermittent serial or progressive
splinting static
• More complex & resistive stiff hand- CMMS
4/6/2022 11

12. Early stiff hand- 3 factors interplay to
create stiffness
4/6/2022 12
Edema
Immobilization
Joint stiffness/
Tissue adherence

13. Evaluation of stiffness
• Edema
• Joint tightness
• Intrinsic tightness
• Extrinsic tightness
• Web space contractures
• Wrist stiffness
• Observing movement
4/6/2022 13

14. Edema
• Excess fluid in interstitial spaces between cells
4/6/2022 14

15. How injured hand develops edema?
• Increased capillary permeability
• Leakage of fluid and proteins into the tissue
spaces
4/6/2022 15

16. Lymphedema
• Lymphatic obstruction- protein accumulation
in the tissue spaces and osmosis of fluid out of
the capillaries
4/6/2022 16

17. Pitting V/s Non- pitting edema
• When edema exists in pockets of free fluid
outside the interstitial spaces, it pits wit
pressure
• These pockets of free fluid can hold more than
½ of the volume of interstitial fluid
4/6/2022 17

18. Dorsal/ palmar swelling?
• Swelling secondary to an infection which may
have originated in the palmar surface is
transported by lymphatics and manifests itself
in the larger, more accommodating area of the
dorsum
4/6/2022 18

19. • Pic- pitting and non pitting edema
4/6/2022 19

20. Edema assessment
 Objective- Volumetric
 Subjective-
– Loss of normal skin creases
– Obscurity of metacarpal head definition
– Oblivion of dorsal finger extensor tendons
4/6/2022 20

21. Evaluation
• Volumetric Displacement
1. Volumetric tank
2. 800 ml collection beaker
3. 500 ml graduated cylinder
4. Water source & towels
4/6/2022 21

22. • Circumferential Measurement
Tape measure – figure of 8
Loop for finger circumference
4/6/2022 22

23. 4/6/2022 23

24. Finger Circumference Gauge
• To measure circumference of a joint or digit
• Wrap webbing around the finger and read
circumference directly from the ruler
• Available in both inches and cm
4/6/2022 24

25. Edema control techniques
1. Elevation
2. Active muscle contraction
3. External pressure from various sources
4. Gentle stimulation- massage
4/6/2022 25

26. Elevation
• Post op.- Hand above elbow , elbow above
heart
• Intermittent active motion of proximal joints- as
large muscles are required to assist venous
return and lymphatic flow
• Balance to be maintained
4/6/2022 26

27. Active motion
• With digital injuries- active MCP motion F,E,
Add, Abd to contract intrinsics
• Intermittent active motion of proximal joints
• No PROM as they do not stimulate muscle
contraction
4/6/2022 27

28. Compression
I. Internal compression- Active muscle
contraction
II. Gentle external pressure- To aid lymphatic
flow
1. Compressive bandages
2. Splints
3. External wraps
4. Gloves
4/6/2022 28

29. Compressive bandages
• Multiple layers of fluffed placed b/w the digits
and applied dorsally & palmarly
• Elastic bandages or POP slabs may be added
to exterior of bandage for more support ad
compression
4/6/2022 29

30. 4/6/2022 30

31. Splints
• Immobilization splint used in acute stage-
4/6/2022 31
Effective rest
Compression
Accurate positioning
Protection of healing structures
Maintain a balanced position

32. • Dorsal and volar plastic slabs
• Dorsal splint for mallet finger
• Gutter finger splint
4/6/2022 32

33. External wraps
• To control digital edema
• In acute stages, must not restrict motion
• Important- Consistency of pressure not intensity
of pressure
4/6/2022 33

34. Gloves
• Convenient & inexpensive
• Fitting like loose second skin
• provide very gentle traction to the skin when
the hand is moved within it
4/6/2022 34

35. Manual Edema Mobilization
• I- Clear and flow exercises
4/6/2022 35

36. 4/6/2022 36

37. 4/6/2022 37

38. 4/6/2022 38

39. • II- MEM massage, drainage and term
description
• Clearing U’s
• Flowing U’s
• Stimulating U’s
4/6/2022 39

40. • III- Incorporation of traditional treatment
techniques
4/6/2022 40

41. Mobilizing early stiff hand
2 basic principles of post op rehabilitation:
1. Minimize effects of immobilization
2. healing tissue must not be overloaded
4/6/2022 41

42. Benefits of early movement
Reestablish tissue homeostasis
Increases venous & lymphatic flow
Increases tensile strength of the wound
Directs alignment & orientation of collagen
fibers
4/6/2022 42

43. Early active motion
• Should be precise
• Avoid substitution using uninjured joints
• Maximum range & repeated intermittently
throughout the day
4/6/2022 43

44. CPM
• Joint motion is needed to preserve joint
lubrication
• Used in immediate post- operative period to
prevent complications not to treat joint
stiffness
4/6/2022 44

45. Blocking motions
• Manual blocking transfers the muscle force to
the targeted stiff joint, enabling the patient to
experience glide at the site of restriction
4/6/2022 45

46. Proprioceptive feedback
• in presence of diminished sensibility-
providing enough resistance to finer flexion to
increase patient’s proprioceptive sense of
digital motion
• Feedback accomplished by patient holding an
object slightly smaller than the available range
of finger flexion.
• E.g : use of a padded handle
4/6/2022 46

47. Passive Range of Motion
• Early post op- joint is positioned slightly
beyond available range
• After edema is diminished, gentle passive joint
motion with traction to the joint
• One gentle, prolonged hold
• Avoid quick forceful stretches
4/6/2022 47

48. Joint mobilization
• For specific capsular tightness with no
accompanying inflammation
4/6/2022 48

49. Muscle isolation/ pattern of motion
• Gentle pull to isolate the desired muscle
• Establish muscle balance
4/6/2022 49

50. Pathological patterns of motion in
early stiff hand
1-Loss of wrist tenodesis pattern
2-Intrinsic plus pattern
3-Intrinsic Minus pattern
4/6/2022 50

51. Loss of wrist tenodesis pattern
• Establishes the normal grasp & release pattern
in hand
• Wrist - key joint to re-establishing the
tenodesis pattern in the hand
4/6/2022 51

52. Intrinsic plus pattern
Normally- IP flexion dominates before MP
flexion starts
Wrist # or FTI-
4/6/2022 52
Limited Extrinsic flexor glide
Initiation from MP joint than IP joint
Intrinsic muscles never get elongated
Adaptively shorten
Mobilization of IP more difficult

53. 4/6/2022 53
Denervation of
intrinsic
muscles
Isolated capsular
tightness of MP joints
Adherence of
extensor tendons on
dorsum of the hand
MP joint flexion is absent
All flexion occurs at IP joints
from extrinsic flexor
muscles
Intrinsic minus pattern

54. • If AROM = PROM , joint ROM is same
regardless of position of proximal joints-
isolated joint capsular tightness
4/6/2022 54
Evaluation of joint stiffness

55. 4/6/2022 55
• Soft & springy end to joint motion
• edema & early stages of collagen
cross linking.
• Active motion & prolonged low load
stress
• Manual PROM
Soft end feel
• Abrupt well defined endpoint to
PROM
• Little edema & more mature cross
linking
• Requires more prolonged periods of
mobilization splinting
Hard end feel

56. Muscle tendon unit tightness
• Shortening of muscle- tendon unit from origin
to insertion
• Occurs secondary to immobilization in
presence of edema
4/6/2022 56

57. Evaluation
4/6/2022 57

58. • Extrinsic tightness
4/6/2022 58

59. Treatment
• Prolonged passive stretching + active use of
muscle through the stretched range
• Splints- all joints crossed by tightness be
included and held at maximum length
4/6/2022 59

60. 4/6/2022 60

61. Tendon adherence
• Joint motion distal to the adherence to
decrease adherence
4/6/2022 61

62. Proximal glide
• Teach patient to isolate & strengthen the
correct muscle to regain full excursion of
adhered unit
• Eg: tendon gliding exercises after flexor
tendon repair
4/6/2022 62

63. 4/6/2022 63

64. Distal glide
• Mobilization splinting
• Only joints distal to site of adherence are
included
• E.g: extensor tendon adherence
- splinting of finger joints in flexion excluding
wrist as adherence id distal to the wrist
4/6/2022 64

65. Skin & scar tightness
• Assessed by Positioning joints so that involved
scar must traverse maximum distance
• Assess for-
Blanching
palpable tightness
immobility of scar or skin
4/6/2022 65

66. • Treatment:
• As the scar reaches maturity, gentle direct
massage using lubricant
• Prolonged periods of holding skin at maximum
length via splinting
• Prolonged serial static splint
• All Joints - proximal and distal
4/6/2022 66

67. Mobilization splinting
• Splinting alone is not adequate but always be
used in conjunction with exercise
• Must out weigh the negative effects of
immobilizations
4/6/2022 67

68. Tissue response
• Short duration force- elastic response
• Prolonged force period - plastic response
Optimal deformation- Low load with
prolonged stress
4/6/2022 68

69. Force application
• No way to measure the amount of stress
needed or the optimal application time
needed
• Goal- to tolerate low tension for longer
periods
4/6/2022 69

70. Types of mobilization splints
4/6/2022 70
Serial static
Dynamic
Static progressive

71. Serial static splint
Immobilises joints in a stationary position
Applied with tissue at its maximum length
Worn for long periods of time to allow tissue
to adapt
Repeated repositioning of the tissues
mobilizes them
4/6/2022 71

72. 4/6/2022 72

73. Dynamic mobilization splints
Force to a specific joint or joints
E.g.. Stretched Rubber band / Spring / Wire
coil generates continues force
Force application is intermittent as the splint
is removed periodically
4/6/2022 73

74. When to use?
When passive motion of joints is responsive to
manual stretch & inflammation has subsided
4/6/2022 74

75. Dynamic extension splint using an outrigger with rubber band
traction to allow active flexion of the digits with passive
extension to neutral
4/6/2022 75

76. Static progressive mobilization
splints
Applied force is not dynamic
Tension on a joint is an adjustable static force
Force maybe applied via hook & loop
When tension is applied, joint is positioned at
its maximum range
The force is adjusted when the tissue
response allows repositioning to a new length
4/6/2022 76

77. • Effective when there is significant resistance at
the end of the passive stretch, especially when
range to be gained is at the end of the normal
maximum
4/6/2022 77

78. Static progressive orthosis- applies flexion
force to gain MCP flexion
4/6/2022 78

79. Static progressive splint for a stiff finger
4/6/2022 79

80. Mobilization splints based on stage of
healing
 During initial healing- static immobilization splints
for protection & to allow inflammation to subside
 During proliferative stage- dynamic splinting
 If continuing inflammation- serial static splinting
 Later stage, hard end feel- serial static splinting or
static progressive splinting
4/6/2022 80

81. Various algorithms that match the type of splint with the phase
of wound healing
4/6/2022 81

82. Basic principles of mobilization
splinting
1. 3 point pressure
2. Distributing pressure evenly
3. Constant prolonged tension
4. Ease of adjustment
5. Provide force perpendicular to the long bone
axis
6. Wearing tolerance
4/6/2022 82

83. 3 Point pressure
PIP extension splinting PIP flexion splinting
4/6/2022 83

84. Distributing pressure evenly
Palmar V/s dorsal skin
Use of dorsal and volar plaster slabs for serial
repositioning of the wrist
4/6/2022 84

85. Constant prolonged tension
• Using minimum force the patient can tolerate
for increasing amounts of time preferred over
increasing amounts of force
4/6/2022 85

86. Ease of adjustment
• Easy to remould, replace and adjust
1. Low temperature thermoplastics used
often
2. POP
3. Brass rods used as out triggers allow
adjustments by bending the wire
4/6/2022 86

87. Provide force perpendicular to the
long bone axis
Static progressive splint- 90 degree line of pull to distal end of
middle phalanx to extend PIP joint
4/6/2022 87

88. Wearing tolerance
Comfort
Precise goniometric measurement before
application
reassessment
4/6/2022 88

89. 4/6/2022 89
Multiple joint stiffness
and extensive tissue
adherence
Chronic Edema, inability
to pump
Ineffectual pattern of
motion, repatterning of
the motor cortex
Chronic Stiff hand

90. Casting Motion to Mobilize Stiffness
4/6/2022 90

91. CMMS
• Use of POP casting
• to selectively immobilize proximal joints in an
ideal position
• while constraining distal joints so that they
move within a desired range and direction
4/6/2022 91

92. Function of CMMS
1. Mobilizes stiff joints
2. Reduces edema
3. Directs a new pattern of motion to revive the
cortical representation of productive motion
4/6/2022 92

93. Why CMMS?
• Active motion regains both active & passive
joint motion
• No PROM , modality or manual treatment is
applied
• Cast immobilizes proximal joints, so the
motion is isolated & part of the hand is
immobilized
4/6/2022 93

94. • CMMS focuses on gaining the motion that is
needed most, which may temporarily cause
loss of motion in the immobilized joints
• In chronically stiff hand, balance of motion is
overwhelming in favor of stiff pattern
• If opposite pattern of motion is allowed to be
the dominant motion until tissues are
mobilized, edema is evacuated & motor
relearning occurs, the opposing motion will
return with time
4/6/2022 94

95. • CMMS can be successful with severe stiffness
that is unresponsive to traditional treatment ,
as the patient is mobilizing only with active
motion, treatment is not painful
• Therapy consists of reevaluation, cast changes
& home instructions, creating a cost effective
approach
• As functional motion is regained, slow
weaning process is started continuing the
progression of mobilization
4/6/2022 95

96. Joint stiffness & tissue adherence
• Active movement mobilizes significant joint
stiffness
• With hand in cast, cyclical motion across the
stiff joints applies positive stress to tissue,
altering cross- linking so tissue resistance
diminishes
4/6/2022 96

97. 4/6/2022 97

98. Edema
• CMMS technique reduces edema by
redirecting active motion to the stiffest area
Concurrent contraction of intrinsic muscles-
moves lymphatic fluid proximally
Active movements of proximal joints- distal to
proximal pumping
4/6/2022 98

99. • Constant but minimal tissue pressure in the
cast- facilitate lymphatic movement
• Movement of the hand within the cast-
pseudo massage of the skin
• POP firmly applied in the palm
• Insulating quality of the cast- neutral warmth,
retaining body heat
4/6/2022 99

100. Change in the pattern of
movement
• Constrained motion within the CMMS cast
demands repetition of correct muscle
movement
• Providing prolonged active movement
necessary to repattern the somatosensory
cortex
• Re patterning is enhanced by conscious,
closed attention to the desired active motion
4/6/2022 100

101. 1. Dominant intrinsic flexion pattern
2. Dominant intrinsic tightness
3. Dominant extrinsic flexion pattern
4. Dominance of isolated joint tightness
4/6/2022 101

102. Dominant interosseous flexion
pattern
• Normal finger flexion- initiated by FDP flexion
of IP joints before MCP flexion
• In stiff hand- digital flexion dominated by
interosseous muscles where finger flexion is
initiated at MCP joints instead of DP joints
4/6/2022 102

103. • Blocking the MCP joints in extension-
recreates the correct initial phase of digital
flexion by isolating FDP muscle, facilitating
FDP glide within DIP joint
4/6/2022 103

104. • After FDP glide is regained & IP joints are
mobilizes into flexion, position of the hood
can be changed and the MCP joints may be
left free to move in concert with the IP joints
4/6/2022 104

105. Dominant intrinsic tightness
• Cast to position MCP joints in full extension
but to allow full IP joint motion- so that
cyclical active digital flexion elongates the
intrinsic muscles
4/6/2022 105

106. Dominant Extrinsic flexion pattern
4/6/2022 106
• Intrinsic minus- when extrinsic rather than
intrinsic muscles control IP joint movement
• Wrist in slight extension and a dorsal hood is
placed over proximal phalanges at their easy
maximum flexion range

107. Dominance of isolated joint
tightness
• CMMS cast- to block all proximal joint
movements
• Wrist and all digits are included- overflow
from the adjacent digital movement will assist
in isolation of the joint motion needed
4/6/2022 107

108. Algorithm
4/6/2022 108
Passive wrist extension to 20- 30 degrees
Serial cast to gain extension if anatomy allows
Possible to initiate finger flexion with FDP , stabilizing wrist in extension
Cast wrist in extension with MP joints blocked in extension
With wrist and MCP joints casted, can FDP initiate Dip joint flexion?
NO
YES
YES
NO
NO

109. 4/6/2022 109
Can FDP initiate finger flexion at DIP joints?
Is finger flexion initiated by interosseous tightness?
Increase relative amount of DIP flexion with hood position
Cast in wrist extension with MP joints in hyperextension
Add dorsal hood for DIP joints in greater flexion than PIP joints
YES
YES
NO
NO

110. 4/6/2022 110
Is finger flexion range and tenodesis pattern maintained out of cast?
Decrease weaning or resume casting
Wean off CMMS cast
Is normal tenodesis and near dull finger flexion demonstrated?
Continue casting YES
YES
NO
NO

111. General Principles of CMMS
application
1. Wrist must always be included in cast in slight
extension
2. Even if stiffness of one digit - include other
digits to allow cortical representation of
uninjured digits
3. Use of POP only -as it has inherent molding
ability
4. Significant time is required to regain mobility
4/6/2022 111

112. Treatment protocols
Based on-
Patient’s individual diagnosis
Response to CMMS
Pattern of motion observed at reevaluation
4/6/2022 112

113. • Cast design-
-determined by pattern of motion
• Time in cast-
-Longer the stiffness has been present, longer
the time required in the cast
• Weaning process-
– slow period of weaning
– Desired ROM outside the cast with spontaneous
tenodesis pattern
4/6/2022 113

114. Contraindications
• Not to be used till therapist has skill in POP
removal & application
• precision is required to block small joints &
allow full motion of adjacent joints
• Claustrophobic patients
• Circumferential cast never be applied to acute
injuries
• Elderly patients with significant OA
4/6/2022 114

115. Surgical Management
4/6/2022 115

116. • Capsulectomy- excision of a capsule- joint
capsule: surgical excision of a portion of a joint
capsule along with the soft tissue structures
intricately associated with the joint
• Capsulotomy- an incision but not excision or
removal of soft tissues
4/6/2022 116

117. Capsulectomy
1. Dorsal MCP joint Capsulectomy
2. Volar MCP joint Capsulectomy
3. Dorsal PIP joint Capsulectomy
4. Volar PIP joint Capsulectomy
4/6/2022 117

118. Dorsal MCP joint Capsulectomy
• Indications:
1. MCP joint Extension Contracture with limitation
in flexion secondary to thickening & contracture
of dorsal capsule
2. Adhesion of extensor tendons to dorsum of the
hand or MCP joint
3. Contracture of collateral ligaments
4/6/2022 118

119. • Diagnosis-
1. MC #, PP # at the base
2. Bony crush injury of the hand
3. Nerve palsies
4. Zone V & VI Extensor tendon repairs
5. Volkman’s contractures
6. Burns
7. Skin contractures
8. Distal radius #with pain and residual hand stiffness
4/6/2022 119

120. • Contraindications:
1. Arthritis
2. Not motivated patients
3. Patients having no specific functional goal
4/6/2022 120

121. Pre- operative assessment
1. Medical history
2. AROM & PROM of all digits & wrist
3. Any intrinsic or extrinsic extensors tightness
4. MMT- extrinsic flexors, extensors and intrinsics
5. Current pain levels and history of pain
6. Skin integrity
7. Previous infections and risk of recurrence
8. ADL- vocational and avocational activities
9. Patient’s desired functional goals of surgery
4/6/2022 121

122. HAND THERAPY
• Post operative therapy-
Examination-
1. AROM, PROM
2. Edema with circumferential measurements
along DPC or along MCP joints
3. VAS
4. Wound- size and appearance
4/6/2022 122

123. Edema management
• Initial 10 - 14 days-
Carefully & evenly applied light compressive
dressing
 elastic stockinettes once that is removed +
edema glove
Elevation & interdigital massage
For digital edema- finger socks or Coban to be
worn between exercises
4/6/2022 123

124. Wound care
• Post operative light compression dressings
4/6/2022 124

125. Pain Management
1. TENS- HIGH tens, conventional tens:
electrode placement along the peripheral
nerve distribution of the surgical area
2. Indwelling pain catheter + oral narcotics
4/6/2022 125

126. Exercises
• To initiate- after removal of bulky compressive
dressing within the initial 24- 48 hours after
surgery
• Before the close of inflammatory phase of
wound healing
• 10 - 15 min every 2 hours
4/6/2022 126

127. Active, active assisted and passive ROM
exercises
1. Composite flexion & extension of the digits
2. MCP joint flexion/extension with IP joints
extended
3. MCP joint flexion/extension with IP joints flexed
4. Abduction/ adduction of digits
4/6/2022 127

128. • For index and small finger- isolate for EDM
and EI
• For tenolysis along with capsulectony- ROM ex
for wrist
• Strengthening ex- after 6- 8 weeks: for long
flexors, extensors and intrinsics after pain &
edema subsides
• Putty, weight cuffs
• Work conditioning program
4/6/2022 128

129. Orthotic devices
• Purpose:
1. Immobilization
2. Maximize passive flexion obtained in surgery
& maintain lengthening of soft tissues
structures
3. Dynamic mobilization to passively enhance
joint ROM
4/6/2022 129

130. Positioning
• Orthosis- MCP 90 flexion (75 acceptable)
Fig 68.12
1. Dynamic Orthosis- if full passive flexion is not
achievable
2. Taping- dorsal taping / composite taping
put pic
4/6/2022 130

131. 4/6/2022 131

132. Scar management
• Scar massage and scar retraction with lotion
1. Deep massage along the length of the scar
2. Horizontally along the scar
3. Circular clockwise and anti clockwise motion
4/6/2022 132

133. Modalities
1. NMES-
1. UST
4/6/2022 133
• Waveform- asymmetrical, biphasic
• Pulse rate: 35 – 40 pulses per second
• Rise time: 2 sec
• On time: 15 sec
• Off time: 20 sec
• Intensity: strong motor response within patient’s
comfort
• Time: 15 min session
• 4 times daily
• Frequency: 3MHz
• Intensity – 0.7 – 1.2 W/cm²
• Mode: Continuous
• Time: 8 min.

134. • CPM
Till 10 days after surgery
Post operative pain and edema
4/6/2022 134

135. Functional Range of Motion
MCP joint – 60
PIP joint – 60
DIP joint – 40
Thumb MCP joint – 20
Thumb IP joint – 18
4/6/2022 135

136. Volar MCP joint Capsulectomy
• Indications
1. Intrinsic contracture secondary to volar plate contractures
2. Burns
3. Volkmann’s contracture
4. Dupuytren’s contracture
5. Crush injuries
6. Spasticity
7. Prolonged immobilization
8. Soft tissue contractures along the volar surface of the MCP joints
9. Burst injuries to palm
4/6/2022 136

137. Post operative therapy
Within 24 hours
Edema & pain control
Orthosis- MCP in extension
Exercises- unrestricted AROM & PROM, active
& passive intrinsic stretches
4/6/2022 137

138. PIP joint capsulectomy
• Residual passive limitation in PIP joint ROM
4/6/2022 138

139. Indications:
1. PP & MP #
2. # dislocations of PIP joint
3. Avulsion of central slip
4. Zone II FTI + lacerations into volar plate
5. Dupuytren’s disease involving PIP joint
6. Lonstanding ulnar nerve palsy
7. Combined ulnar or median nerve palsy
8. Skin contractures 2o to burns or STI
4/6/2022 139

140. Dorsal PIP joint capsulectomy
• Post op.- start 24 - 36 hours after surgery
• Bulky compressive dressing to be replaced by
light compressive dressing to hand & forearm
+ digital dressing
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141. • Exercises-
• Active, active- assisted & passive ROM to
entire hand for 10 – 15 min every 2 hourly
• MCP joints positioned in 60 - 75 flexion with
actively extending PIP joints in maximum
extension
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142. • Extensor tenolysis + capsulectomy- isolated
passive flexion of PIP joint
• Within 7 – 10 days- composite passive flexion
• Extension orthosis- DIP extension
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144. Volar PIP joint capsulectomy
• Post op.- start 24 - 36 hours after surgery
• Bulky compressive dressing to be replaced by
light compressive dressing to hand & forearm
• digital dressing
• Edema & pain control – in initial days
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145. • Active, active- assisted & passive ROM to the
digits & wrist every 2 hours 10 - 15 minute
sessions
• Passive PIP joint extension
• Actively & passive hold the end ROM for 5 sec
min. actively & 10 sec passively
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146. • Tenolysis + capsulectomy-:
• Tendon gliding exercises- 5 exercises??
• Orthosis- in full extension
• TENS
• NMES
• UST
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