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Physical Therapy Management of Hand Fractures
Sandra Richards Saunders
PHYS THER. 1989; 69:1065-1076.
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Physical Therapy Management of Hand Fractures
Hand fractures can be a complicated management dilemma for both the general
clinician and the specialist. To better equip the therapist to treat fractures in the
hand, a brief review of bone and articular cartilage healing and the effects of
immobilization are reviewed. Active, passive, and resistive exercises for the patient
with hand fracture are reviewed in addition to treatment of the associated problems of scar formation, edema, and pain. Static and dynamic splinting techniques
are also discussed. [Saunders SR: Physical therapy management of hand fractures.
Phys Ther 69:1065-1076, 1989]
Sandra Richards Saunders
Key Words: Hand injuries; Orthopedics: fractures, upper extremity; Orthotics/
splints/casts, upper extremity.
Fractures in the hand are very common. Some fractures are stable and
have good functional results without
immobilization.1 When the fractures
are open, comminuted, or associated
with significant soft tissue injury, the
results are less satisfactory.1-3 The
hand is composed of 19 bones (14
phalanges and 5 metacarpals), over 30
tendinous insertions, and numerous
intricate structures. An intricate balance of these structures produces the
stability and mobility required in normal hand function. The healing process, especially when adjacent soft
tissue is damaged, follows the principle of "one-wound" healing.4 That is,
all structures damaged by the injury
heal as one. Appropriate therapy can
make a significant difference in the
functional outcome.5
The purpose of this article is to provide a rationale for determining the
application of external forces (ie,
active, passive, continuous passive,
and resistive motions and splinting) as
they relate to the problem of hand
fractures. A brief review of long bone
and articular anatomy is presented as
an introduction to long bone and
articular cartilage healing. The influence of rigidfixationimmobilization
on healing is discussed in addition to
associated problems such as scar formation, edema, pain, and non-union
fractures.
Long Bone Healing
Anatomy
The metacarpals and phalanges are
considered long bones although their
shaft diameter-to-length ratio is proportionally greater than the more
commonly studied long bones such as
the humerus and femur. Figure 1 is a
schematic diagram of the anatomical
structure of a long bone (ie, the
femur). Long bones consist of compact bone surrounding a medullary
cavityfilledwith marrow. The epiphyseal region contains cancellous bone
with a thin layer of compact bone on
the exterior. The shaft is surrounded
by periosteum, which is composed of
a fibrous outer layer and a more cellular inner layer called the osteogenic
layer.
S Saunders, MS, PT, is Senior Hand Therapist, The Richmond Upper Extremity Center, 7113 Three
Chopt Rd, Suite 203, Richmond, VA 23226 (USA).
Bones consist of several types of cells.
The cells that are active during development and fracture healing are
called osteoblasts. Osteoblastic cells
secrete an organic intercellular substance, or matrix. The matrix hardens,
and the osteoblasts are entombed in
lacunae or nest within the intercellular substances just secreted. At that
point, the cell is called an osteocyte.
The layers of intercellular substance
(the lamellae) surrounding the osteocyte are constructed such that each
lacuna containing an osteocyte is connected by small tunnels called canaliculi to a central canal containing a
vessel, thus creating an avenue for the
flow of tissue fluid for nutrient
exchange. Bone receives its blood
supply from three sources: 1) nutrient
arteries that pierce the shaft of the
bone and branch into two longitudinal vessels, 2) periosteal vessels, and
3) branches from vessels that supply
the joints. Transport of nutrients to
the osteocyte is then accomplished by
a complex system of canals (haversian
and Volkmann's) and canaliculi.
The cellular and intercellular substances of compact bone and cancellous bone are similar except for their
geometric shape. The lamellae of
compact bone are laid down concen-
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1065/73
the osteoid tissue and cartilage known
as the external callus can be seen
only if it is also absorbing calcium
salts. Calcification of bone is a process
of the amorphous calcium salt
CA3(PO4)2 from the circulating blood
being laid down in the organic
matrix, which then becomes crystalline in form.7
Classification of Fractures
Cowin describes cortical bone as
"slightly stiffer than most woods, to
have roughly the same stiffness as
brick, sandstone or lead and to have
about 1/4 the stiffness of aluminum
and about 1/10 the stiffness of
steel, " 8 ( P 1 5 9 ) Despite these characteristics, fractures do occur. Fractures typically occur in planes perpendicular to
the force. The lower the rate of load
of the force, the rougher the resulting
fracture surface. This roughness
occurs as a result of osteon pulling
out.9 In compression fractures, the
fracture line is oriented 60 degrees to
the load axis. Torsion fractures result
from a shear failure along the cement
line, which is the three-dimensional
region between adjacent osteons.10
These biomechanical principles help
Fig. 1. Schematic diagram of anato understand the following classificatomical structure of long bone. (Inset tion of fractures of the hand.
shows lamellae arranged into osteons.)
(Reprinted with permission from Gardner
Metacarpal and distal phalanx fracED, etal,Anatomy: Regional Study of
Human Structure, ed 4, Philadelphia, PA, tures are usually classified with
W B Saunders Co, 1975, p 9.)
respect to location, whereas proximal
and middle phalangeal fractures are
trically around a central canal containclassified first as either articular or
ing a vessel. The structure containing
nonarticular and then by location.11
osteocytes arranged in lamellae comThe long bones of the hand are
municates with a centrally located
divided into four segments: 1) the
vessel called an osteon, or haversian
base at the proximal pole, 2) the
system. The osteons run longitudinally shaft, 3) the neck, and 4) the condyle
in the shaft of the bone and may be
at the distal pole.
several millimeters in length. Cancellous bone, also referred to as spongy
Isolated fractures of the base of the
or trabecular bone, has larger spaces
metacarpals of the second and third
and less solid matter, or matrix, than
digits are rare and of minimal consenoncancellous bone.6
quence because the motion of these
joints is small. Fractures at the base of
The ability of the bone to bear weight
the fifth digit are more common and
is due, in part, to the deposition of
usually the result of a longitudinally
calcium salts in the intercellular subdirected force. Frequently, this injury
stance. Without the calcification prois associated with a proximal and dorcess, bone remains flexible.7 Also,
sal subluxation of the metacarpalroentgenograms only outline bone
hamate joint. Proper diagnosis is diffithat is calcified. In fracture healing,
cult, but important, because of the
74/1066
insertions of the extensor carpi
ulnaris and flexor carpi ulnaris muscles through the pisometacarpal ligament. Misdiagnosis can lead to persistent pain or loss of grip strength.
Metacarpal shaft fractures are usually
produced by longitudinal compression, torsion, or direct impact. This
type of fracture can be transverse
(perpendicular to the long axis of the
bone), spiral (spanning an acute angle
to the long axis of the bone), short
oblique (to a transverse fracture), or
comminuted (many bone fragments).
Many of these fractures are inherently
stable, and some may not need immobilization. The determining characteristics of the fracture are its stability
and the maintenance of rotation and
length. There is a discrepancy in the
acceptable amount of rotation and
shortening to allow full range of
motion and grip strength. Smith and
Peimer state that no more than 10
degrees is acceptable in the second
and third digits and 20 degrees in the
fourth and fifth digits.12 Brown advocates open reduction internal fixation
(ORIF) if the metacarpal is shortened
more than 3 to 4 mm.13
Fractures of the metacarpal neck usually result from direct impact by a
fisted hand. For this reason, they are
commonly called "boxer's fractures."
There is usually a dorsal angulation of
the fracture fragment because of the
deforming force of the interosseous
muscles and the direction of impact.
A larger degree of angulation is
acceptable, especially in the fourth
and fifth digits, because of the mobility at the carpometacarpal (CMC)
joints.11,12 The angulation can be
reduced by flexion of the metacarpophalangeal (MCP) joints, allowing
treatment by dorsal reduction in
many cases.
Proximal and middle phalanx fractures are generally classified as either
articular or nonarticular. In all articular fractures, early motion is essential,
especially if the proximal interphalangeal (PIP) joint is involved. Condylar fractures are common in athletes
but often overlooked as a sprain
because the athlete is able to move
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the finger. The fracture can be either
condylar or bicondylar and often
requires ORIF. If the condyle is comminuted, internal fixation is not
possible.
Fractures of the base of the phalanx
can produce a dorsal, volar, or lateral
fracture fragment. Depending on the
proximity of the fracture to the lateral
bands, the oblique retinacula ligament, or the volar plate and the
potential of adhesions between these
ligamentous structures and the healing fracture, a pseudoboutonnière
deformity can develop.14 The patient
exhibits PIP joint flexion and distal
interphalangeal (DIP) joint extension.
Fracture dislocations, common at the
PIP joint, can be classified as either
stable or unstable, depending on the
percentage of articular surface
involvement and the proximity to the
attachment of supporting soft tissue.11
Last, long spiral fractures can be intraarticular. The fracture may involve
enough of the articular surface to
cause fracture slippage, creating a
block tofingerflexion.
Monarticular fractures of the proximal
and middle phalanges can also occur
in the neck, shaft, or base as with
metacarpal fractures. Neck fractures
are common in children and are
often treated closed. Shaft fractures
can also be transverse, oblique, spiral,
or comminuted as can metacarpal
fractures. Transverse fractures are
more common in the middle phalanx,
whereas oblique and spiral fractures
are more common in the proximal
phalanx. Open or closed reduction is
determined by the degrees of stability,
angulation, and rotation. Factors such
as the pull of the flexor digitorum
sublimus (FDS) tendon and the central slip of the extensor digitorum
communis (EDC) tendons15 and the
direction of force of injury determine
the type of deformity.16 Fractures of
the base of the proximal or middle
phalanges can be reduced by MCP
joint flexion, so they are often treated
by closed manipulation if displaced.
Distal phalanx fractures, especially of
the tuft and shaft, are easily treated by
two weeks of splinting because of the
good soft tissue support dorsally by
the nail and volarly by the pulp and
fibrous septa. The tuft fractures are
usually a result of a crush injury to
thefingertip,and the shaft fractures
are usually open as a result of a partial amputation. Externalfixationis
necessary only when the soft tissue
support is destroyed.
Fractures at any site can be open or
closed. Open fractures are more difficult to treat than closed fractures
because of the associated soft tissue
damage and potential adhesions to
the fracture site. Even in a closed fracture, the adjacent soft tissue and periosteum are usually torn, and a bone
fragment may be displaced. Compromised circulation in the haversian
vessels results in death of osteocyte,
as evidenced by empty lacunae on
each side of the fracture line.
Articular Cartilage Healing
Articular fractures of the PIP joint
pose a particular challenge to the
hand therapist because of the injury
intolerance of the PIP joint and the
close proximity of the tendon sheath
and volar plate. Repair of articular
cartilage when the underlying bone is
fractured is due in part to the callus
formation of the healing bone. As previously discussed, chondrocytes form
in the absence of blood supply, but as
the circulatory repair catches up with
the osteogenic proliferation, the cartilage is partially replaced by bone
rather than by cartilage. If this replacement occurs, traumatic arthritis
can develop.17
Movement has been shown to influence the healing process of
cartilage.18 Salter et al showed that
four weeks following femoral condyle
fracture, the gap in the cartilage was
filled with loose, ordinary connective
tissue and blood vessels when the
joint was immobilized.19 In contrast,
after four weeks of continuous passive
motion (CPM), a gap in the cartilage
had closed without invasion of tissue
from the underlying bone. Salter et al
believed that repair occurred because
motion provided a fresh supply of
synovialfluid,thus supplying ade-
quate nutrition for cartilage to grow
in an avascular environment.19
Bone Healing by
Immobilization Versus
Internal Fixation
Immobilization
Generally, hand fractures are treated
by immobilization with a cast or
splint. Osteogenic cell proliferation
occurs in the deep layer of the periosteum on each side of the fracture site
as dead osteocytes undergo lysis. The
cell proliferation lifts the fibrous layer
of the periosteum from the bone, initiating the formation of an external
callus. Within the first week, a slower
osteogenic cell proliferation (internal
callus) occurs in the lining of the
marrow cavity.
The osteogenic cells of the external
callus proliferate and become osteoblasts on the deep surface of the periosteum and chondrocytes superficially. This differential development is
dependent on how rapidly repair
occurs and the stability of the fracture.
Because capillary growth is slower
than osteogenic proliferation and
bone forms only in the presence of
sufficient blood supply, cartilaginous
repair (pseudoarthrosis) or non-union
fractures can result in the presence of
compromised blood supply or movement about the fracture site. Under
normal circumstances, as the cartilage
of the callus becomes calcified, the
chondrocytes die, and thus cartilage is
progressively replaced by bone of the
cancellous type. This calcified cartilage is the fusiform mass seen at the
fracture site on roentgenograms.
Healing by internal callus formation
occurs as osteoclasts ream out the
canals of the dead trabecular bone.
Osteoblasts lay down new haversian
systems on each side of the fracture,
and immature bone fills the inevitable
space between fragments. At this time,
the fracture line is not seen on roentgenograms. Full remodeling takes
place between 8 to 10 weeks postinjury, and consolidation is finished by
12 weeks postinjury.20
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Internal Fixation
Internal fixation by pins or screws is
also a common technique for management of hand fractures. The healing process then occurs by internal
callus formation with very little or no
external callus formation.20 The
amount of external callus depends on
the degree of movement allowed at
the fracture site. The more rigid the
fixation, the less the external callus
formation.20 Internal fixation appears
to act as the external callus, thereby
not allowing movement and eliminating the stimulus for external callus
formation. If external callus is seen,
the internal fixator is probably not
stable and additional immobilization
may be needed.
Internal fixation is often the treatment
of choice for fractures in the hand
because the margin of error is so
small. For example, the rotation of a
metacarpal fracture 2 to 3 degrees
will be amplified distally, causing the
finger of the involved ray to rotate
and frequently cross-over on the adjacent finger. If the fracture surfaces of
an oblique phalanx fracture slip, the
result can be a shortened digit.
There are sixfixationimplants used
in hands: wire sutures,13,21 Kirschner
wire (pin),22 screws, plates,23 intermediary rods, and externalfixators.Fixation with plates and screws is biomechanically the strongest fixation
available for small bones.24 Screws are
appropriate for spiral and long
oblique fractures. Percutaneous pinning using Kirschner wires is also
popular because the wires are relatively easy to insert, provide adequate
stability, and require limited surgical
exposure for insertion.22 They are
subject, however, to loosening and
migration. They do not provide a
rigidfixation,but thefixationis
secure enough to allow early
motion.22
Intra-articular fractures must be analyzed by the physician with the specific anatomy of the hand in mind and
treated individually. An avulsion of the
flexor digitorum profundus (FDP)
tendon with an associated distal pha-
76/1068
lanx avulsion fracture is more appropriately treated early with pull-out
wires, thus allowing early motion.25
An avulsion fracture of the terminal
tendon of the EDC tendon, however,
will require open reduction or percutaneous pinning if more than 30% of
the insertion is involved.26 If not, the
patient will suffer an extensor lag
known as a mallet finger.
Management of fractures about the
PIP joint is frequently controversial.
For example, condylar fractures of the
middle phalanx are usually managed
by immobilization because the fracture fragments tend not to displace.
However, fractures involving the volar
plate must be evaluated with respect
to PIP joint hyperextension. Bowers et
al showed that 35 degrees of hyperextension of the PIP joint occurred
when both osseous attachments to the
middle phalanx are sectioned.27
Condylar fractures of the proximal
phalanx, therefore, require open or
percutaneous reduction. Generally, a
fracture involving greater than 25% of
the articular surface will require internalfixation,which results in good
stability and ROM. As mentioned previously, fracture dislocations at the PIP
joint have a worse prognosis.11
Treatment Application of
External Forces
Physical therapy intervention consists
of the application of external forces in
the form of exercises, modalities, or
splinting to influence the healing and
remodeling process. As previously
mentioned, compromised circulation
or excessive movement at a fracture
site can lead to non-union fractures.
Conversely, movement at a joint after
injury promotes articular cartilage
regeneration. Immobilization, even in
the absence of fracture, produces considerable resorption of bone tissue.28
Long-axis loading, however, increases
bone density29 by deposition of new
lamina at the surface of bone. In view
of these facts, active, passive, and
resistive exercises and splinting can
greatly influence bone and articular
cartilage healing as well as functional
outcome. The order of treatment
depends on the nature of the injury.
In the case of an avulsion fracture or
a fracture in which the bone fragment
provides attachment of a tendon, passive motion in a noncompromising
direction can be initiated prior to
active motion. Splints can be fabricated to allow motion in one direction and assistive motion in the reciprocal direction. In most cases, active
motion can be initiated prior to passive motion because of the proximity
of the tendon insert to the joint, thus
using a shorter lever. Most important,
the anatomy of the injury must be
known by the therapist to ensure safe
early motion.
Active Motion
Active range of motion (AROM) is
begun as soon as possible after a phalanx or metacarpal fracture. If a fracture is fixed internally, active motion
can commence early.24 For most phalangeal and metacarpal fractures
treated by simple immobilization,
active motion can commence at three
weeks.
Active motion should include specific
tendon gliding of the FDP, FDS, EDC,
extensor indicis (EI), and extensor
digiti quinti proprius (EDQ) tendons
as well as the intrinsic tendons. These
motions can produce four beneficial
results: 1) prevention of adhesions
from bone to tendon (osteotenodesis), one tendon to another tendon,
or tendon to skin (dermotenodesis);
2) increased circulation about the
fracture site, especially in metacarapal
fractures; 3) decreased edema; and
4) compression at the fracture site.30
To promote selective tendon gliding,
closing the hand should be performed in one of three ways: 1) claw
fist—flexing the DIP and PIP joints
simultaneously while maintaining the
MCP joints in extension, thus requiring the FDP tendon to glide on the
bone (Fig. 2); 2) sublimus fist—
flexing the MCP and PIP joints while
maintaining the DIP joint in extension, thus requiring the FDS tendon
to glide on the stationary FDP tendon
(Fig. 3); and 3) fullfist—flexionof all
three joints simultaneously, thus promoting the gliding of the FDP and
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Passive Motion
Fig. 2 .
claw fist.
Fig. 3 .
FDS tendons on each other. These
exercises were demonstrated advantageous in improving tendon motion by
Wehbe31 and Wehbe and Hunter.32,33
Using metal tags and serial roentgenograms, they demonstrated that 49 mm
of FDS tendon excursion and 50 mm
of FDP tendon excursion are necessary to move from full finger-wrist
extension to full finger-wrist flexion.
Moving from the full fist to the claw
fist requires 11 mm of glide with the
FDS tendon and 12 mm of glide with
the FDP tendon.
Selected tendon glide of the FDS and
FDP tendons should also be
performed. The FDS tendon can be
selectively glided by actively flexing
the PIP joint of the injured ray while
positioning the remaining fingers' DIP
joints in extension. Because the FDP
Sublimits fist.
tendons have a common muscle belly,
the remaining fingers should be free
of all restraint while gliding the FDP
tendon by active isolated flexion of
the DIP joint.
The EDC tendons must glide on the
underlying bone and the EI and
EDQ tendons on the adjacent EDC
tendon. The EDQ and EI tendons
glide when the long horn sign
(extension of the second and fourth
digits) is made, and this maneuver
must not be overlooked when dealing with fractures of the second and
fourth digits. Tendon gliding of the
EDC tendon is performed by
extending the MCP joints while the
IP joints are flexed.
Passive range of motion (PROM) can
be in the form of physiological
motion or arthrokinematic (accessory)
motion.34 Physiological motion is traditionally thought of as PROM using
long levers to move the joint, whereas
arthrokinematic motion is the type of
motion used in joint mobilization and
involves movement of the joint surfaces on each other. Once the location of the fracture site is known by
the therapist, joint mobilization can
be started earlier than traditional
PROM because the line of application
of force can be directed perpendicular to the joint surface, thus not stressing the fracture site. Again, the timing
of initiation of joint mobilization is
dependent on the structures involved
in the injury. Joint mobilization can
be initiated as early as active motion
when structures resisting the direction
of force are not involved in the injury.
Communication with the physician
regarding specifics of the injury is
essential for safe, early mobilization
(physiological or arthrokinematic). In
physiological PROM, the force is
applied at a distance from the joint
axis of motion; therefore, torque can
be produced about the fracture site.
For this reason, physiological passive
motion cannot be initiated as early as
arthrokinematic motion.
The degree of reduction of the fracture must be known to the therapist
before realistic PROM goals can be
set. Compression of the fracture may
result in shortening, angulation, or
rotational malalignment of the bone.
Any abnormality must be known by
the therapist so that the joint is not
traumatized. For example, a volar,
displaced intra-articular fracture of the
distal aspect of the proximal phalanx
may be inhibiting the volar glide of
the middle phalanx on the proximal
phalanx. Thus, forceful physiological
flexion will result in dorsal joint
levering (ie, opening like a book),
producing abnormal biomechanics
and capsular pain. Full PROM may not
be a realistic goal until the mechanical block created by the displaced
bone fragment is addressed surgically.
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Full PROM is necessary before full
AROM can be obtained and before
ultimate function of the hand is
achieved. Because the collateal ligaments of the PIP joint are at maximum length in extension,35 it is
important to obtain full PIP joint
extension as soon as possible. A
patient can functionally tolerate a 10to 15-degree flexion contracture, but
a much greater contracture will interfere with placement of the hand in
small places. The most common complaint when a patient has 30 degrees
of flexion contracture of the PIP joint
is catching the finger on a pocket
when attempting to retrieve change
from a pants pocket. To address this
problem, the patient can drag the
digit through putty on a table to passively extend the joint (Fig. 4).
Continuous passive motion is a relatively new PROM modality available to
the hand therapist. As stated earlier,
PROM has been shown to assist in
articular cartilage healing, to reduce
swelling, and to reduce stiffness.36
Because CPM is a form of PROM, it
can be applied as soon as physiological PROM is allowed. The decision to
use CPM should be a joint decision by
the therapist and the physician based
on the nature of the injury, anticipated amount of scarring, and current
lack of motion. It must be remembered that CPM applies a force
through a lever arm (the phalanx),
thus applying a torque to the fracture
site. Continuous passive motion
should not be painful. The advantage
for the apprehensive patient is that
there is a definite and consistent end
range, which can be slowly increased
as ROM increases and anxiety
decreases. Clinically, CPM would be
ideal for the patient with an intraarticular fracture and a known history
of heavy scarring or a fracture or dislocation of the PIP joint. Any patient
whose pain and edema exceed expectations may benefit from CPM.
The term continuous passive motion
is misleading because CPM is rarely
used continuously in our clinic (The
Richmond Upper Extremity Center
[RUEC]) or by other hand therapists.
In our clinic, we have also used CPM
78/1070
Fig. 4. Putty-dragging exercise to promote proximal and distal interphalangeal
joint extension.
Fig. 5. Patient demonstrating continuous passive motion offifthdigit's proximal
interphalangeal joint.
as a progressive static splinting technique (Fig. 5), serially increasing ROM
to the patient's tolerance. It might be
argued that CPM is less effective in
improving ROM than dynamic splinting because a relatively short percentage of treatment time is spent at the
extremes of ROM. The two treatments, however, should be viewed as
separate modalities with separate purposes. Continuous passive motion has
the potential of decreasing edema37
and improving synovial fluid
production.38 Dynamic splinting for
joint contracture does not make this
claim. Continuous passive motion,
however, can never replace active and
resistive exercise.
Resistive Motion
Light resistance can begin at four
weeks postinjury11 in most phalangeal
and metacarpal fractures treated by
immobilization, especially if the roentgenogram shows bone remodeling in
the fracture area. If healing has not
commenced, then active motion only
would be continued. If the fracture is
fixed by percutaneous pinning, resistive exercise should be delayed until
the pins are removed.
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Fig. 7 .
Fig. 6. Weight-well exercise. Note
degree of distal and proximal interphalangeal joint flexion needed with smalldiameter dowel.
Resistive motion is important not only
in the improvement of grip strength
but also in bone healing if these intermittent forces exerted on the fracture
site are compressive and do not exert
a displacing force.30 Roentgenographic
reports must be reviewed by the therapist to begin such early treatment.
Obviously, a flexor tendon avulsion
fracture or a displaced spiral fracture
are not candidates for early resistance.
Light resistive exercise also aids in
scar remodeling and therefore
improved motion. The resistance can
be in the form of graded putty exercises for flexion using the three fist
positions described earlier. Other
types of resistive exercises; such as
the weight-well exercise, can be
implemented gradually (Fig. 6). The
weight-well exercise strengthens the
long finger flexors (FDP and FDS
Patient using BTE Work Simulator® to perform work hardening.
muscles) as well as the wrist musculature. The diameter of the dowel is
important to the goal of full finger
flexion. To promote full DIP joint
flexion and more pull by the FDP
tendon, a smaller diameter dowel
should be used.
The resistive exercise program should
include functional activities and work
simulation as soon as possible. In our
clinic, the BTE Work Simulator®* (Fig.
7) is used to promote selective tendon gliding. For example, the BTE
Model 151 gripper tool* can be used
in two different ways to promote
either FDS (Fig. 8) or FDP (Fig. 9)
tendon gliding. This device can also
be used to simulate pliers. The BTE
Work Simulator® has numerous
attachments to simulate anything from
ironing and vacuuming to hammering, climbing a ladder, or pulling
sheet metal. The advantage of the BTE
Work Simulator® is that resistance can
be added gradually as the injured part
can tolerate the load and a measured
force (in inches-pounds) is known for
each exercise bout.
Splinting
The use of static and dynamic splinting in the treatment of hand injuries
is essential in many cases to maximize functional outcome. For example, static splinting can be used to
provide stability to the fracture site,
yet is removable, thus allowing
early controlled exercise. The optimal position of immobilization for
the maintenance of the maximum
length of the collateral ligaments is
at least 50 degrees of MCP joint
flexion and full interphalangeal (IP)
joint extension. 39 This optimal position is not always possible because
of the location of fracture site with
respect to structures such as ligaments, tendons, or volar plate
inserts. The physician will try to
position the fingers as close to this
optimal position as possible. The
static splint can then be progressively remodeled to approximate IP
joint extension with MCP joint
flexion as additional motion is
gained.
*Baltimore Therapeutic Equipment Co, 7455-L New Ridge Rd, Hanover, MD 21076-3105.
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Static splints can also be designed
to allow movement at a particular
joint while providing circumferential compression and stability to the
fracture site. Proximal interphalangeal joints become stiff very easily. Early active motion is a key to
full ROM.5 Figure 10 depicts a splint
fabricated for a patient whose pins
were removed early because of
infection. The splint was designed
to stabilize proximal phalanx fractures of the second and third digits
and the middle phalanx fracture of
the fifth digit. Burkhalter described
the use of a similar type of casting
technique for acute injuries that
allows protected active motion
while resisting displacing forces.40
The principle of dynamic splinting
is to apply low-load, long-duration
force to a joint in a specific direction to improve passive extension
or flexion.41 The prefabricated
extension splints can be used in PIP
joint flexion contractures of less
than 45 degrees. Fess showed that
the spring finger extension splint† is
effective for a flexion contracture of
8 to 45 degrees and the Capener
splint for a flexion contracture of 10
to 20 degrees, whereas none of the
prefabricated splints are effective for
contractures over 45 degrees.42 For
contractures of this magnitude, a
customized splint must be fabricated. A customized dynamic splint
can provide a line of force perpendicular to the phalanx being moved.
None of the prefabricated splints
achieve this force in contractures
greater than 45 degrees.42
For dynamic flexion splints, customized splints function best. As stated
earlier, the line of force applied by
the splint must be perpendicular to
the phalanx being moved. If not, compressive and distractive forces will be
applied to the joint, which will cause
pain and irritation of the joint.41 For
this reason, dynamic splints must be
monitored closely and readjusted to
†
Fig. 8. Use of BTE Model 151 gripper tool to promoteflexordigitorum sublimits
tendon glide.
Fig. 9. Use of BTE Model 151 gripper tool to promoteflexordigitorum profundus
tendon glide.
meet the changing demands of the
joint. The optimal tension exerted by
the splint has been described by
Brand as 200 to 250 g.43
Distributed by Rolyan Medical Products, N93 W14475 Whittaker Way, PO Box 555, Menomonee
Falls, WI 53051.
80/1072
Dynamic splints may also be used to
position a joint in an optimal position, yet allow light resistive motion.
For example, an intra-articular fracture of the PIP joint can be treated
using a dynamic PIP joint extension
splint. A thin rubber band attached
to a cuff around the middle phalanx
would maintain the PIP joint in
Physical Therapy/Volume 69, Number 12/December 1989
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Fig. 10. Three views of splint used to stabilize proximal phalanx fractures of second and third digits and middle phalanx frac
offifthdigit, yet allow movement at proximal interphalangeal joints. (A = volar view; B = radial view; C = dorsal view.)
extension while allowing small
amplitudes of motion into flexion.
This splinting technique will allow
synovial fluid lubrication of the
articular cartilage and promote healing by cartilage rather than bone
formation.
Management off Associated
Problems
Scar formation, edema, and pain are
all part of the healing process, but any
one of these sequelae can be excessive and therefore a problem that
must be addressed. These restrictions
are obvious in the open fractures
requiring reduction, but they can also
create similar problems in the closed
fracture treated by immobilization.
The closed injury producing a fracture also traumatizes the surrounding
soft tissues. These tissues heal during
the inflammatory period by subsequent scar formation; therefore, the
potential for pain and excessive
edema and scar formation is present.
Full ROM is the optimal goal, and
early motion promotes full ROM.
Scar Formation
Collagen synthesis, or scar formation,
is the method by which the body
heals, but it also can restrict ROM.
Scar formation can be viewed as a
necessary evil that must be controlled.
In hand injuries, this phenomenon is
addressed in the one-wound concept.4
Because of the close proximity of
structures in the hand, tendons, ligaments, and periosteum of bone can
heal within a continuous sheet of scar,
therefore limiting motion between
the structures. One of the most common problems is adhesions of the
flexor tendons to bone and surrounding structures after a fracture. Collagen synthesis peaks at two weeks
postinjury, and scar maturation ensues
through the formation of covalent
bonds over the next two to four
weeks. Thereafter, maturation
declines but persists up to nine
months.44 Early active motion is the
most effective treatment to avoid
excessive scar adhesions between
structures, but prevention of excessive
scar formation is not always possible.
Treatment must then be directed
toward influencing the scar maturation process. Vibration (mechanical
pressure) and long-term pressure
(static force) on the scar can influence
the process along with active and
resistive exercises.45-46 Theoretically,
vibration can be used as a disorganizing force on the scar tissue in preparation for the organizing force produced by active motion (Fig. 11).
Otoform®† secured by Coban®
wrapping‡ can be used to apply continuous pressure on the scar (Fig. 12).
Pressure on the scar provides the
stimulus to slow scar formation and
avoid keloid formation.45,46
‡
3M Co, Medical-Surgical Div, Bldg 225-5S, 3M Center, St Paul, MN 55144-1000.
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1073/81
Fig. 1 1 . Vibration of volar surface of
hand.
Fig. 1 3 . Compression of digit byCoban®wrapping.
Fig. 12.
Otoform® secured to digit by
®
Coban wrapping, used to apply continuous pressure on scar.
Fig. 14. Use ofJobstair splint to reduce hand edema.
hand splint§ (Fig. 14) or an elasticized
glove.
Edema
The inflammation process is essential
to healing, but excessive edema can
impede healing and motion. The
same principles of edema control can
be applied to the hand as elsewhere
in the body: ice, elevation, and compression. Compression of a finger can
be accomplished by Coban® wrapping
(Fig. 13). Compression of the entire
hand can be accomplished by a Jobst
§
Pain
Pain can restrict motion and strength
and must be controlled to effectively
implement treatment. Transcutaneous
electrical nerve stimulation can be
used prior to, during, or after treatment. If it is known that the fracture
is healed and the surrounding tissue
is not hyperreactive, high frequency
Jobst Institute, Inc, PO Box 653, Toledo, OH 43694-0653.
82/1074
TENS can be administered to the fracture site prior to and during treatment (Fig. 15). If the healing status of
the fracture is not known, TENS can
be used after treatment to alleviate
pain. If the pain is of ligamentous,
capsular, or tendinous origin, other
pain-relieving modalities such as ultrasound or phonophoresis can be used.
Treatment should end with a cold
modality to decrease potential swelling and pain caused by treatment.
Treatment must not be painful when
treating patients with hand injuries
because pain may indicate soft tissue
injury leading to increased edema,
increased pain, and decreased ROM.
Physical Therapy/Volume 69, Number 12/December 1989
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rection. Treatment consisted of joint
mobilization, AROM exercises, and
Coban® wrapping. Her PIP joint
AROM improved to 10 degrees of
extension to 92 degrees offlexionin
one month, but the fracture was still
painful and a non-union fracture was
still evident on roentgenograms. At
that time (three months after injury),
resistive exercise and high frequency
TENS over the fracture site were initiated. In two months, full ROM was
restored and a callus could be seen
on roentgenograms. The callus formation was attributed to the combination
of motion and TENS.
Summary
Treatment of patients with sustained
Fig. 15. Use of transcutaneous elec- hand fractures requires an advanced
trical nerve stimulation through fracture
knowledge of wound healing and
site during exercise.
hand anatomy. This advanced knowledge is important because of the
If soft tissue injury occurs, the strucproximity
of structures in the hand
tures must be immobilized with static
and
the
necessity
for the structures to
splinting. Small-amplitude, pain-free
glide
on
each
other.
Structures can be
motions can maintain joint mobility
moved
early
after
injury,
especially if
while the irritated structure is allowed
fixed
internally.
Treatment
consists of
to rest.
active, passive, and resistive exercises.
Splints are used statically to immobiNon-union Fractures
lize the injured joint in a position
advantageous to the recovery of full
As mentioned earlier, two conditions
ROM or dynamically to increase ROM.
contribute to non-union fractures:
Management of scar formation, and
1) poor blood supply and 2) excessive
pain are essential in treatment of a
movement at the fracture site. On
hand injury because of the functional
roentgenograms, a gap between the
importance of the hand and the small
bone fragments will be visible. Even
margin for error biomechanically.
though the external callus formation
may be extensive, the gap will be
present and may even widen. In a
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Physical Therapy/Volume 69, Number 12/December 1989
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Physical Therapy Management of Hand Fractures
Sandra Richards Saunders
PHYS THER. 1989; 69:1065-1076.
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