Dr Muntasir Mannan Choudhury Dept of Hand and Reconstructive Microsurgery Singapore General Hospital Dept of Orthopedic Surgery Senkang General Hospital

1. Dr Muntasir Mannan Choudhury
Dept of Hand and Reconstructive Microsurgery
Singapore general Hospital
Dept of Orthopedic Surgery
Senkang General Hospital
REHABILITATION OF
HAND FRACTURES

2. KEY POINTS TO COVER
• Principles of rehabilitation
• Effect of early mobilization on healing
• Resting splints
• Special dynamic splints
• Active mobilization in fracture
• Controlling swelling
• Evaluating outcomes in fractures

3. INDICATIONS FOR FIXATION OF HAND
FRACTURES
• Unstable fractures
• Open fractures
• Comminuted displaced fractures
• Fractures associated with joint dislocation or subluxation
• Displaced or angulated or malrotated spiral fractures
• Displaced intra-articular fractures, especially around the PIP
joint
• Fractures in which there is loss of bone
• Multiple fractures

4. • Hand’s propensity to quickly form a permanently
stiffening scar, unstable fractures must be surgically
converted to stable fractures to allow early ROM
exercises.
• Failure to use early ROM will result in a stiff hand with
poor function regardless of radiographic bony healing.
• Maureen A. Hardy, S. Brent Brotzman, Steven R. Novotny,Fractures and Dislocations of
the Hand

5. GENERAL APPROACH TO EARLY
RETURN OF FUNCTION
• Postop immediate immobilization in position of safe immobilization
• Wound care
• Pain control
• Edema control
• Scar therapy
• Resting splints
• Early mobilization
• Tendon gliding exercises
• Progressive mobilization with indication of bone healing
• Strengthening and functional therapy

6. WHY DO WE GET STIFFNESS OF THE
FINGERS?
•

7. Let the Journey begin from the
operation theatre to your clinic
and then to the room of your
friendly Hand Therapist and end
with a happy functional patient

8. POSTOP IMMEDIATE IMMOBILIZATION IN
POSITION OF SAFE IMMOBILIZATION

9. DISCHARGED WITH ANALGESIA
• Digital blocks, wrist block, wound infiltration with
anesthesia
• Paracetamol
• NSAIDS

10. 1ST POSTOPERATIVE VISIT
• Dressing removed, the wound is evaluated
• Protective splint is fashioned for wear when
not performing therapeutic exercises.
• Fixation using Kirschner wires
• provides only limited stability
• should be approached in a manner
more similar to conservative treatment
measures until you are completely sure
of the stability of the fixation

11. EDEMA CONTROL
• Swelling is considered an indirect
measure of inflammation
• May be objectively quantified using a
water volumeter or with wrist and digit
circumference measurements.
• The simplest intervention - elevation by
way of increased central venous return.

12. SCAR MASSAGE AFTER SUTURE
REMOVAL
• Sutures removed POD 10, and massage initiated
• Applies direct compression to edematous tissues
• Ability to disrupt fibrous tissue adhesions, which naturally occur as tissues
heal.
• Enhance tissue compliance and minimize the formation of tendon adhesions.
• Mild lotion may also be incorporated for patient comfort and to address dry
skin.
• Scar massage also contributes to desensitization of the incision
• Peyton L. Hays, Tamara D. Rozental; Rehabilitative Strategies Following Hand FracturesHand Clin 29
(2013) 585–600

13. EARLY MOBS WITHIN 7 DAYS AFTER THE
OPERATION
• Start immediate ROM exercises for the unaffected joints
• Patients are instructed to perform range of motion exercises of the shoulder
and elbow to prevent stiffness and loss of motion.
• particularly important with the older patient with a diminished activity
level.
 If the fracture has been treated with rigid internal fixation, movement can
start almost immediately
 Exercises are initially performed actively without resistance
 Continue for 3 weeks until further bone healing evident on radiographs
 TERRI SKIRVEN, OTR/L CHT: REHABILITATION AFTER FRACTURES OF THE HAND;
Operative Techniques in Orthopaedics, Vol 7, No 2 (April), 1997: pp 152-160

14. • Active motion - under direct patient control via cortical
processing and activation of musculotendinous units
• Generates tendon gliding, promote strength and endurance, and enhance lymphatic drainage.
• Generates a local compressive effect to the surrounding skin, subcutaneous tissues, and
lymphatic system
• Active-assisted motion - combines active muscle recruitment
with patient- or therapist-assisted motion.
• This type of exercise is especially useful in hesitant or guarding patients.
• A low-load, passively applied force is used to enhance the patients’ own active
contribution
• Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: a systematic
review. J Hand Ther 2004;17:118–31

15. • Multiple studies demonstrate the
benefits of early rehabilitation and
range of motion, especially for high-
energy and open fractures
• Skirven TM, Osterman AL, Fedorczyk J, et al, editors. Rehabilitation of the hand and upper extremity. 6th edition.
Philadelphia: Elsevier Mosby; 2011. p. 361–76.
• Feehan LM, Bassett K. Is there evidence for early mobilization following an extraarticular hand fracture? J Hand Ther
2004;17:300–8.

16. PASSIVE RANGE OF MOTION EXERCISES
• Approximately 3 weeks after fixation
• As active range of motion is restored and with continued
evidence of fracture healing, progression to passive motion
exercises is allowed
• If the fixation is deemed very stable , can start gentle PROM
earlier.
• Passive exercise must be performed within the pain tolerance of
the patient.
• Overly aggressive passive exercise can cause inflammation,
increased stiffness and pain, and limit progress

17. • Passive motion consists of a short, externally
applied, high load across a joint.
• The therapist or patient applies a steady load to
the point of maximum tissue resistance. Flexion
bands may be used to place and hold flexion
across the joint
• As fracture healing allows, resisted motion is
incorporated into the therapy regimen as a means
of further enhancing motion while restoring
strength and endurance to the injured hand
• Peyton L. Hays, MD, Tamara D. Rozental;
Rehabilitative Strategies Following Hand
Fractures. Hand Clin 29 (2013) 585–600

18. TENDON GLIDING AND BLOCKING EXERCISES
• Tendon gliding promotes the motion of
tendons through their sheaths and prevents
soft tissue adherence.
• Blocking and tendon glide exercises may be
performed with the aid of the uninjured hand
or with a blocking splint fabricated by thw
hand therapist
• Only 1to 2 mm of tendon motion is necessary
to prevent adhesion

19. INTRINSIC AND EXTENSOR TENDON
GLIDING
• Intrinsics:
• Intrinsic muscles are activated by holding the MCP
joints in flexion while flexing and extending the IP
joints.
• Placing the palm flat on a table and then elevating
the digit off of the table
• Extensors:
• Patients flex and extend the MCP joints while
maintaining the IP joints in a flexed position

20. STRENGTHENING
• Once fracture healing has occurred and range of motion has been restored, progressive
strengthening exercises may be incorporated into the therapy regimen.
• Muscle strengthening further enhances soft tissue glide and range of motion, thereby
preventing late adhesion formation.
• Exercises selected for their particular area of weakness: Flexion, extension, adduction,
and abduction strengthening exercises can be performed using putty
• Neuromuscular electrical stimulation for wasting and weakness

21. FUNCTIONAL PHASE
• Functional phase of therapy prepares patients for return
to work and hobby with exercises aimed at integrating
work- or life-specific skills into the rehabilitative program

22. SPLINTING IN REHABILITATION OF HAND
FRACTURES
• Commonly described splints:
• Static
• Serial static
• Dynamic
• Static progressive

23. STATIC SPLINTS
• Static splints maintain the hand or digit in a single
fixed position.
• Commonly applied during the early inflammatory
phase following acute injury or surgery.
• Static splints protect injured tissues, maintain
fracture reduction and alignment, and assist in the
resolution of local inflammation and swelling.
• It is usually worn for the first few weeks during
periods of rest in between therapy
• K wire fixation

24. SERIAL STATIC SPLINTS
• Useful in the management of digit contractures and
early stiffness, especially of joints with hard end
points of motion.
• The angle of positioning is changed periodically
• Serial casting may also address noncompliant splint
wear
• require regular removal and reapplication
because tissues relax under prolonged
• Prospective study comparing serial casting methods
for PIP joint contractures, Flowers and LaStay found
that a longer duration of cast wear (6 days vs 3 days
before cast change) resulted in greater motion gains

25. DYNAMIC SPLINTING
• Dynamic splints are fabricated to deliver controlled,
continuous force across a mobile joint.
• Load application is typically via elastic traction bands
or springs.
• Dynamic splints, such as the 3-point LMB finger
extension splint (DeRoyal, Powell, TN), are especially
useful in treating stiff joints that are responsive to
passive stretch or joints with soft motion end point

26. THE EFFECTIVENESS OF DYNAMIC SPLINTING IN
THE TREATMENT OF STIFF JOINTS
• In a prospective case series of PIP joint flexion contractures, the
dynamic splint wear of 8 to 12 hours per day over an average of
4 months led to an average gain of 18 degrees extension.
• Several factors are associated with improved outcomes
following dynamic splinting shorter time between injury and
initiation of therapy, flexion deficits, and the presence of greater
pretreatment motion
• Prosser R. Splinting in the management of proximal interphalangeal joint flexion contracture. J Hand Ther
1996;9:378–86.

27. REHAB REGIMES AS SPECIFIC TO FRACTURE
FIXATION

31. MEASURES OF REHABILITATION
PROGRESS
• The most commonly followed parameters
are range of motion and strength.
• Range of motion is best measured with a metal digital goniometer placed
along the dorsum of the digit.
• Measurements are taken at each joint with the hand in full composite
flexion and likewise in full extension. – TAM calculated
• Total passive motion is similarly measured with the small joints placed in
maximum passive flexion and extension.
• If full composite flexion of the hand is lacking, the distance of the fingertip
from the distal palmar crease should also be measured and recorded,
• Osterman AL, Fedorczyk J, et al, editors. Rehabilitation of the hand and
upper extremity. 6th edition. Philadelphia: Elsevier Mosby; 2011. p. 55–71.

32. GRIP AND PINCH STRENGTH
• Motor strength testing is a useful measure of hand
functional recovery, especially as patients prepare to
return to work and recreational activities.
• Grip is measured using the Jamar dynamometers
• Measurements are taken with the shoulder in 0 degree adduction,
elbow at 90 flexion, and the forearm in neutral
• The right and left sides are sequentially tested a total of 3 times, and
the average for each side is recorded
• O’Driscoll SW, Horii E, Ness R. The relationship between wrist position, grasp size, and
grip strength. J Hand Surg 1992;17A:169–77

33. • Pinch strength is measured for the
injured and uninjured hands.
• lateral key pinch (thumb pulp to index
finger middle phalanx)
• 3-point or chuck pinch (thumb pulp to
index and middle finger pulps)
• Fingertip pinch (thumb tip to index
finger tip)

34. FUNCTIONAL OUTCOME MEASURING
TOOLS
• Numerous patient-reported outcome measures are available.
• The most widely used and well validated measures
• General Medical Outcomes Study 36-Item Health Survey
• The extremity-specific Disabilities of the Arm, Shoulder, and
Hand (DASH) and Quick DASH
• The hand-specific Michigan Hand Outcomes Questionnaire
• Fess EE. Functional tests. In: Skirven TM, Osterman AL, Fedorczyk J, et al, editors.
Rehabilitation of the hand and upper extremity. 6th edition. Philadelphia: Elsevier Mosby;
2011. p. 152–62

35. THANK YOU