Introduction

• Rehabilitation is an integral part of the treatment of hand and wrist injuries. It may be used throughout the patient's treatment course.

• Most patients with hand and wrist injuries can be treated with a general program that emphasizes splinting, edema control, range of motion, and strengthening.

• A subset of hand and wrist injuries requires specific rehabilitation protocols.

• Patients who fail to obtain adequate range of motion can be treated with dynamic and static splinting.

Figure 42-1 The intrinsic plus position is used when splinting to prevent contractures.

blocks motion. Second, edematous fluid that is high in protein leads to fibroplasia and scarring (Fig. 42-2).

A number of techniques are used to decrease postinjury edema. Splints described in the previous section minimize the effects of edema on soft tissues. Elevation is extremely important in the early phases of injury. Hand elevation above the heart may be accomplished in a number of ways. A simple method available to nearly all patients is taping a pillow (or two if needed) around the forearm at night. This prevents the hand from falling to or below the level of the heart. Soft foam forearm upper extremity splints are commercially available and accomplish the same goal.

External compression also reduces edema but must be used judiciously in the early period. Patients must be monitored for compartment syndrome and capillary refill must be checked. Ace bandages provide compression while also allowing tissue expansion. They are useful in the acute phase and help prevent complications from constrictive dressings. Coban (3M, Minneapolis, MN), a self-adhesive wrap, is used in the subacute period. One-inch Coban is wrapped around digits in a retrograde fashion (Fig. 42-3). Patients are taught how to check for capil-

Figure 42-2 An edematous hand after cast removal in treatment of a metacarpal fracture.

lary refill. The wrap is removed after 20 to 30 minutes. Larger areas of edema in the subacute period are controlled with com-pressive sleeves or gloves or an intermittent pneumatic compression garment.

Active exercise is a very useful way of reducing edema and is used as the rehabilitation process progresses. Muscle contraction decreases hydrostatic pressure and interstitial volume. This increases lymphatic and venous return, which removes fluid from the extremity. Active motion through a full range is emphasized as limited motion will not achieve this result.

Range of Motion

Some injuries, such as tendon lacerations, ligament ruptures, and fractures require joint immobilization or specific limitations on motion in the first few weeks. Other injuries tolerate early active range of motion. The benefits of active range of motion include decreased edema, increased joint nutrition, and prevention of muscle atrophy. As a general rule, active range of motion is initiated once the injury stabilizes and is capable of withstanding forces generated by an active motion protocol.

A six-pack hand exercise program is often recommended by physicians and therapists (Fig. 42-4). When done properly, it ranges every joint in the digits and is the first set of hand exercises taught. Joint blocking techniques concentrate the patient's effort on specific joints and are used when isolated areas of digital stiffness are identified. Wrist flexion, extension, radial, and ulnar deviation exercises are also taught. Circumduction of the wrist allows patients to perform all these motions. Finally, forearm supination and pronation exercises are taught. Patients can view this motion best while holding a pen in their fist with the arm at the side and the elbow flexed 90 degrees. A hammer, or other heavy object, is used as a gentle assist if desired. Supination is often difficult to regain after distal radius fractures, and this exercise is emphasized once immobilization is discontinued.

Gentle active-assisted motion is useful when patients have difficulty regaining motion. Passive or forceful manipulation is avoided. This tears tissue and adds to the cycle of pain, edema, stiffness, and scarring. Continuous passive motion machines stretch tissue in a slow, sustained way, avoid problems with passive manipulation, and may benefit patients by preventing contractures. Unfortunately, continuous passive motion does not have the beneficial effects on edema and muscle tone that active range of motion does and is not a substitute for it.

4- Straighten fingers as much as possible.

1- Make a tabletop with fingers by keeping the wrists and the end and middle joints of the fingers straight and bending only at base joints (knuckles).

2- Keep base joints (knuckles) and wrist straight; bend and straighten the end and middle joints of the fingers.

3- Make a fist, being sure each joint is bending as much as possible.

4- Straighten fingers as much as possible.

5- Make an "O" by touching thumb to fingertips one at a time. Open hand wide after touching each finger.

6- Rest hand on table with palm down. Spread fingers wide apart and bring them together.

Figure 42-4 The six-pack hand exercise program.

Strengthening

Strengthening is the final phase of hand and wrist rehabilitation and is performed once a functional range of motion is achieved and after bone, tendon, and ligament healing has occurred. A variety of exercise products are available to assist in rehabilitation of the injured athlete's hand. Rubber band grippers and Theraputty are used for strengthening grip and intrinsic and extrinsic hand musculature. Free weights, elastic tubing, Thera-Band, and weight-lifting equipment are used in training facilities, clinics, and homes to strengthen the proximal larger muscles of the wrist, elbow, and shoulder. A home exercise program with diagrams is provided to increase patient under standing and compliance. Lower weights and higher repetitions are initially used. Patients progress to heavier weights as tolerated.

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