Zone-specific pitfalls in flexor tendon rehabilitation: management and prevention.

Despite significant advancements in flexor tendon repair techniques and rehabilitation strategies, achieving complete restoration of digital motion remains a formidable challenge. The most prevalent complications associated with tendon repair are the development of tendon adhesions and joint contractures. Left unaddressed, these complications can further lead to secondary pathomechanical changes, resulting in fixed deformities significantly affecting hand function. This review of zone-specific considerations in flexor tendon rehabilitation provides an in-depth analysis of the dynamics of tendon motion after repair and strategies to minimize common secondary complications.

Alternative Noninvasive Treatment of Unstable Extra-articular Proximal and Middle Phalangeal Fractures: A Static Linear Traction Orthosis Design.

Extra-articular unstable proximal and middle phalanx fractures are typically managed with surgical means with common complications of tendon tethering, stiffness, and secondary hand dysfunction. As a result, alternative conservative measures are being explored. The use of static linear traction through the application of an orthosis allows for fracture reduction and anatomic healing, with successful range of motion outcomes.

Rehabilitation Following Nerve Transfer Surgery.

Nerve transfer surgery is an important new addition to the treatment paradigm following nerve trauma. The following rehabilitation plan has been developed over the past 15 years, in an interdisciplinary, tertiary peripheral nerve program at the "Roth|McFarlane Hand and Upper Limb Centre." This center evaluates more than 400 patients with complex nerve injuries annually and has been routinely using nerve transfers since 2005. The described rehabilitation program includes input from patients, therapists, physiatrists, and surgeons and has evolved based on experience and updated science. The plan is comprised of phases which are practical, reproducible and will serve as a framework to allow other peripheral nerve programs to adapt and improve the "Roth|McFarlane Hand and Upper Limb Centre" paradigm to enhance patient outcomes.

Use of Thermoplastic Rings Following Venting of Flexor Tendon Pulleys: A Biomechanical Analysis.

PURPOSE: Normal digital flexion relies on flexor tendon pulleys to convert linear muscular force to angular digital motion. However, there is a growing trend to vent them partially during flexor tendon repair. The objective of this study was to examine the effects of a thermoplastic ring, acting as an external pulley, on flexor tendon biomechanics and finger range of motion (ROM) after pulley venting. METHODS: We tested 15 cadaveric digits using an in vitro active finger motion simulator. We measured loads induced by flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) as well as joint ROM with sequential sectioning of the A2, A3, and A4 pulleys compared with an intact pulley condition. At each stage, external thermoplastic pulley rings were applied snugly over the proximal and middle phalanges to recreate A2 and A4 function, respectively. RESULTS: After complete venting of the A2, A3, and A4 pulleys, proximal interphalangeal joint ROM significantly decreased by 13.4° ± 2.7° and distal interphalangeal joint ROM decreased by 15.8° ± 2.1°. Application of external rings over the proximal and middle phalanx resulted in a residual ROM decrease of 8.3° ± 1.9° at the proximal interphalangeal joint and 7.9° ± 2.1° at the distal interphalangeal joint, nearly restoring ROM. Similarly, complete pulley venting resulted in reduced FDS load by 37% and FDP load by 50% compared with intact pulleys. After application of external rings, loads were restored almost to normal, with a 9% reduction for FDS load and 9% reduction for FDP load compared with intact pulleys. CONCLUSIONS: The application of thermoplastic rings acting as external pulleys is an effective, noninvasive, and reproducible approach to restore flexor tendon biomechanics and digit ROM after pulley venting. CLINICAL RELEVANCE: Thermoplastic rings may be a useful therapeutic adjunct in restoring joint ROM and flexor tendon loads after surgical venting of the pulleys.

The Use of Dynamic Assist Orthosis for Muscle Reeducation following Brachial Plexus Injury and Reconstruction.

Therapeutic management of brachial plexus injuries remains complex. The impact of brachial plexus injuries on everyday human functioning should not be underestimated. Early active-assisted range of motion following such injuries may prevent myostatic contractures, minimize muscle atrophy, facilitate muscle fiber recruitment, and enable a faster return to baseline strength levels. The dynamic assist elbow flexion orthosis proposed is designed to provide patients with a graded system for muscle reeducation and function. No clinical data are currently available on the use of this orthosis design; however, this article presents a treatment option based on sound clinical reasoning to facilitate rehabilitation following this devastating injury.

The Effect of Simulated Total Distal Interphalangeal Joint Stiffness on Grip Strength.

PURPOSE: Production of a functional grip pattern requires the concerted action of numerous structures within the hand. This study quantifies the effect of total distal interphalangeal joint (DIPJ) stiffness to grip strength. METHODS: Fifty (25 men, 25 women, 100 hands) individuals with a mean age of 38 years (range: 17-69 years) were recruited. Exclusion criteria included history of previous upper limb injury, neuropathies, or systemic disease. Custom thermoplastic orthoses were used to splint participants' DIPJ in full extension simulating stiffness. Grip strength before and after splinting was measured using a calibrated Jamar dynamometer. Data were analyzed using paired and independent sample t tests and 2 × 2 repeated-measures analysis of variance with hand dominance and configuration (splinted or unsplinted) as within-subject factors. RESULTS: Restriction of DIPJ flexion led to a 20% decrease in grip strength (P < .001). There was no significant difference in this decrease between dominant and non-dominant hands. Univariate analysis did not demonstrate any interaction between hand dominance and testing configuration. Post hoc analysis revealed no statistical difference in baseline grip strength between the dominant and non-dominant hands. Furthermore, men had significantly stronger grip strength than women in all configurations (P < .001). CONCLUSIONS: Flexion at the DIPJ contributes significantly to grip strength, and stiffness at this joint greatly limits functional capabilities of the hand. This necessitates the need for targeted rehabilitation in DIPJ injuries to minimize adverse effects on grip strength.

OBJECTIF: Pour produire un schéma de préhension fonctionnel, il faut l'action concertée de multiples structures de la main. La présente étude quantifie l'effet de la raideur de toute l'articulation interphalangienne distale (AIPD) sur la force de préhension. MÉTHODOLOGIE: Les chercheurs ont recruté 50 personnes (25 hommes, 25 femmes, 100 mains) d'un âge moyen de 38,28 ans (plage de 17 à 69 ans). Les critères d'exclusion incluaient des antécédents de blessure d'un membre supérieur, de neuropathie ou de maladie systémique. Les chercheurs ont utilisé des orthèses thermoplastiques sur mesure pour mettre une attelle sur l'AIPD en pleine extension des participants, afin de simuler la raideur. Ils ont mesuré la force de préhension avant et après la pose de l'attelle à l'aide d'un dynanomètre Jamar calibré. Ils ont évalué les données à l'aide de tests de Student appariés et indépendants et de l'analyse de variance à mesures répétées 2×2 et se sont servis de la dominance de la main et de la configuration (avec ou sans attelle) comme facteurs individuels. RÉSULTATS: La restriction de la flexion de l'AIPD suscitait une diminution de la force de préhension de 20 % (P < 0,001). Il n'y avait pas de différence significative entre les mains dominantes et non dominantes. L'analyse univariée n'a pas démontré d'interaction entre la dominance de la main et la configuration des tests. L'analyse a posteriori n'a révélé aucune différence statistique de la force de préhension entre les mains dominantes et non dominantes en début d'étude. De plus, les hommes avaient une beaucoup plus grande force de préhension que les femmes dans toutes les configurations (P < 0,001). CONCLUSIONS: La flexion de l'AIPD contribue de manière significative à la force de préhension, et la raideur de l'articulation limite considérablement la capacité fonctionnelle de la main. Ainsi, il faut prévoir une réadaptation ciblée des lésions de l'AIPD pour en réduire le plus possible les effets indésirables sur la force de préhension.

Rehabilitation considerations in the management of terrible triad injury to the elbow.

An elbow dislocation associated with a radial head and coronoid fractures is termed a terrible triad. This injury almost always renders the elbow unstable requiring surgical intervention. The primary goal of surgery is to stabilize the elbow to permit early motion to prevent stiffness. Recent literature has improved our understanding of elbow anatomy and biomechanics as well as the pathoanatomy of this injury. This article reviews key concepts that will allow the surgeon and therapist to apply an systematic rehabilitation approach when managing such injuries.

Postoperative management of extensor pollicis longus repairs within close vicinity to or within the extensor retinaculum.

Therapists are continually modifying tendon protocols as part of the quest to create the perfect balance between tendon protection and tendon glide. Although much literature exists on the rehabilitation of the long flexor and extensor tendons to the digits, little literature exists on the rehabilitation of the extensor pollicis longus (EPL) tendon. This author used concepts related to tendon glide, tendon tethering, and early active mobilization to create a new splint and subsequent protocol for patients after an EPL laceration near the extensor retinaculum.

Contribution of the ulnar digits to grip strength.

PURPOSE: To determine the contribution of ulnar digits to overall grip strength. SUBJECTS: Fifty individuals (25 men and 25 women; 100 hands) with a mean age of 35.6 years (range 19 to 62 years) were tested. Exclusion criteria included previous history of hand injuries, entrapment neuropathies and systemic diseases. METHODS: Ethics approval was granted before testing. A calibrated Jamar dynamometer (Lafayette Instrument Company, USA) was used to test subjects in three configurations: entire hand - index, middle, ring and little fingers; index, middle and ring fingers; and index and middle fingers. Little and ring fingers were excluded using generic hand-based finger splints. The order of testing was kept constant, and subjects were tested three times on each hand for each configuration. The average of the three trials at each configuration was recorded. Subjects received 1 min of rest between each testing configuration. The data were analyzed using a 3×2 repeated measures ANOVA with hand dominance and configuration as the within-subject factors, followed by two independent sample t tests to compare flexor digitorum superficialis (FDS) independence and FDS nonindependence on right and left hand grip strength measurements in the index, middle, ring and little condition. RESULTS: Univariate results demonstrated that grip strength was significantly predicted by the interaction between hand dominance and configuration, while the parsing of the interaction term demonstrated greater grip strength across all levels of configuration for the dominant and nondominant hand. There were no significant differences between FDS independence and FDS nonindependence for either hand on grip strength. DISCUSSION: The results indicate a significant decrease in grip strength as ulnar fingers were excluded. Furthermore, exclusion of the little finger has differing effects on the grip strength of the dominant and nondominant hands - the dominant hand had a greater loss of strength with the little finger excluded than the nondominant hand. CONCLUSIONS: The ulnar two digits play a significant role in overall grip strength of the entire hand. In the present study, exclusion of the ulnar two digits resulted in a 34% to 67% decrease in grip strength, with a mean decrease of 55%. Exclusion of the little finger from a functional grip pattern decreased the overall grip strength by 33%. Exclusion of the ring finger from a functional grip pattern decreased the overall grip strength by 21%. It is clear that limitation of one or both of the ulnar digits adversely affects the strength of the hand. In addition, there was no significant difference between grip strength of FDS-independent and FDS-nonindependent subjects for either hand.

Postoperative management of carpometacarpal joint fracture dislocation of the hand: A case report.

Injury to the carpometacarpal joints is rare. The strong ligamentous attachments and carpal bone alignment readily resist displacement. To the authors' knowledge, there are no studies evaluating postoperative recovery regimens of carpometacarpal fracture dislocations. The present study describes a postoperative hand therapy regimen that used a novel carpometacarpal brace permitting early mobilization.

Client satisfaction of hand therapy intervention: An evaluation of the effectiveness of therapy for clients recovered from complex regional pain syndrome.

Complex regional pain syndrome (CRPS) is a neuropathic pain condition that may develop following trauma to an extremity. Clients treated for CRPS at St Joseph's Health Care London - Hand and Upper Limb Centre, London, Ontario, were asked to evaluate their level of satisfaction with the treatment they had received by comparing their pain, functional status and emotional status before and after receiving therapy. The results indicated a high level of satisfaction among clients, attributable to the unique nature of the therapy program in use at this facility, where the occupational therapist works in close collaboration with the surgeon and pain specialists, and the therapy regimen is designed for each client individually according to his or her needs. The unique contribution of the present study to the body of clinical literature on CRPS is that it introduces a focus on client functionality and on client satisfaction with therapy received.

Dynamic assist splinting for attenuated sagittal bands in the rheumatoid hand.

The extensor mechanism of the hand is complex, requiring effective functioning of all involved structures, including the sagittal bands. The sagittal bands function to maintain the extensor tendons in midline and to limit their distal excursion. Injury to the sagittal bands or sagittal band attenuation can cause instability and ulnar displacement/subluxation of the extensor tendons into the valleys between the digits and lead to a subsequent loss of active finger extension at the metacarpophalangeal joints. Secondary conditions may also develop, such as swan-neck deformity, as is frequently observed in the rheumatoid arthritis population. To prevent or reduce an extension lag and secondary changes and to maintain the functional use of the hand, a dynamic metacarpophalangeal extension assist splint is necessary. This splint enables extension at the metacarpophalangeal joints, thus enabling the functional use of the hand. This article reviews the biomechanics of the sagittal bands and the corrections that enable finger extension at the metacarpophalangeal joints, thus preventing secondary conditions.

Extensor quadriga: Pathomechanics and treatment.

The extensor tendons to the index, long, ring and small fingers are motored by the common extensor digitorum communis muscle body. Effective function of this muscle can only occur if the gliding amplitude of each of its four extensor tendons is normal. As a corollary, limitation of the excursion of any of the individual tendons by adhesions at a fracture or tendon repair site, a fixed flexion contracture at the metacarpophalangeal joint, or by rupture, attenuation or laceration of a saggital band or juncturae tendinum, will result in reduction of the excursion of the adjacent extensor tendons. This pathological state has been termed the extensor quadriga because of its similarities to the analogous pathology affecting the flexor digitorum profundus system. Improper management of this clinical entity may lead to an abnormal pathomechanical kinematic chain imbalance. Early identification and treatment is critical to address this entity appropriately.

Les tendons extenseurs de l'index, du majeur, de l'annulaire et de l'auriculaire sont mus par le muscle extenseur commun des doigts. Mais celuici ne peut fonctionner adéquatement que si l'amplitude de glissement de chacun des quatre tendons extenseurs est normale. En corollaire, une restriction de mouvement de l'un ou l'autre des quatre tendons, due à des adhérences en un foyer de fracture ou au siège de réparation d'un tendon, à une contracture fixe en flexion à une articulation métacarpo-phalangienne ou encore à une rupture, à une faiblesse ou à une lacération d'un ligament sagittal ou du tendon commun, entraîne une restriction de mouvement des tendons extenseurs adjacents. On a donné à ce syndrome le nom de « quadrige des extenseurs ¼ en raison de ses ressemblances avec un syndrome analogue qui touche le muscle fléchisseur commun profond des doigts. Un traitement inapproprié de ce trouble clinique peut conduire à un déséquilibre de la chaîne cinématique pathomécanique. Aussi est-il crucial de reconnaître et de traiter précocement ce syndrome afin d'en assurer une prise en charge adéquate.