refer to wrist extension, and metacarpophalangeal (MCP)/interphalangeal (IP) joint flexion, respectively) The “safe” position for splinting of the hand is also known as “intrinsic plus” and involves placing the joints into positions which will minimize stiffness and loss of motion based on hand anatomy principles. The position includes the wrist at 20 to 30 degrees of extension, the MCP joints at 70 to 90 degrees of flexion, and the IP joints at 0 to 20 degrees of flexion. This position is also sometimes known as the Edinburgh position as originally described by James.1,2 This position ensures appropriate tension on the collateral ligaments and volar plates of the wrist and finger joints so that shortening and subsequent flexion contractures are less likely to occur. It also maximizes function if stiffness persists in the splinted position (Fig. 88.1). 20° -30° 70° -90° 0° -20° Fig. 88.1 Safe position for splinting of the hand (also known as intrinsic plus position).
2. James JIP. The assessment and management of the injured hand. Hand 1970;2(2):97–105 finger? The figure-of-eight splint is shown in Fig. 88.2. This is useful in cases of swan-neck deformity. The swan-neck deformity is characterized by hyperextension at the proximal interphalangeal (PIP) joint combined with flexion at the distal interphalangeal (DIP) joint. It is caused by an imbalance of muscle and tendon forces within the digit and can occur as a result of many different problems, including but not limited to: volar plate injury at the PIP joint, generalized hyperextensibility, MCP joint volar subluxation (as occurs in rheumatoid arthritis), flexor digitorum superficialis (FDS) tendon injury, intrinsic muscle contractures, and chronic mallet finger. The primary problem is often disruption of the volar plate at the PIP joint which allows the joint to slide into hyperextension. A chronic mallet injury can lead to transference of DIP joint extension forces into PIP extension forces. An FDS rupture can lead to unopposed PIP joint extension with gradual attenuation of volar plate integrity, or unmasking of underlying volar plate Fig. 88.2 Figure-of-eight splint. laxity. When the PIP joint hyperextends, tethering of the lateral bands by the transverse retinacular ligament at PIP joint level restricts their transmission of force to the terminal tendon, i.e., DIP joint extension; so, the DIP joint tends to exhibit an extension lag and the PIP joint extension may be further exaggerated. The figure-of-eight splint serves to restrain the extending PIP joint in a mild degree of flexion while still allowing active flexion and extension without a cumbersome dorsal splint or adhesive tapes; therefore, it is usually readily tolerated. In fact, some companies manufacture ornamental swan-neck splints that serve as functional jewelry. Buddy taping is useful for managing collateral ligament injuries of the digit as well as some closed fractures of the digits and hand. It relies on the principle that the adjacent uninjured digit supports the injured digit through a safe range of movement to minimize stiffness while protecting any healing structures. Hyperextension splints are static splints used for the management of terminal extensor tendon disruption (mallet finger). Holding the DIP joint in hyperextension can help maximize approximation of the tendon end to its bony insertion. Dorsal blocking splints can be made for many purposes. For example, they are useful short-term for volar plate injuries to facilitate early mobilization while avoiding hyperextension. The splint angle is usually progressively reduced as weeks go by. They are also useful for flexor tendon repair protocols. Ulnar gutter splints are useful for 4th and 5th ray injuries, such as metacarpal fractures and carpometacarpal (CMC) joint fracture dislocations to immobilize the injured digits whilst allowing movement of the uninjured digits.1–3
3. Lalonde D. Managing Boutonniere and swan-neck deformities. BMC Proc 2015;9(Suppl 3):A50 One of the key principles in fracture management using splints is that the joint proximal and the joint distal to the fracture site should be immobilized within the splint. As with many rules in medicine, there are exceptions. For example, in some metacarpal injuries the MCP joints are left free. However, this is a general principle that is usually followed. Dynamic splints are useful for managing some intra-articular joint fractures, as they can be used to hold the joint out to length (i.e., distract it), while facilitating early range of motion (ROM) to reduce long-term stiffness and to encourage healing of a damaged joint surface in a functional contour. Examples include the Suzuki frame and the Giddins frame; each used for PIP joint injuries.1,2 The short-arm splint is used for wrist and metacarpal stabilization, as opposed to the humerus. The sugar tong splint is so named because of its similarity to tongs used to pick up sugar cubes. It prevents forearm supination and pronation; so, for example, it can be useful for some distal radius, ulnar styloid, and carpal bone fractures, along with elective procedures involving the distal radioulnar joint. The free ends are volar and dorsal at the level of the metacarpal heads, with a continuous slab passing along the dorsal and volar aspects of the forearm and around the elbow (which is flexed at 90 degrees). The ulnar gutter splint is generally used to immobilize the 4th and 5th metacarpals after injury rather than the ulnar itself. One key element to ensure when applying splints is that superficial nerve locations are well padded to prevent neuropraxia. Splint materials are exothermic; so, adequate padding is also required to avoid contact burns.3,4
4. Bullocks J, Hsu P, Izaddoost S, et al, eds. Plastic Surgery Emergencies. Principles and Techniques. 2nd ed. New York, NY: Thieme; 2017 This patient should be placed in a forearm-based dorsal blocking splint (not volar) which should pass distally to just beyond the fingertips. This is to protect the repair from excessive extension and should be worn for 4 to 6 weeks. Patients with such injuries usually need to be mobilized early to prevent adhesions and stiffness, and this can be done using either an active or a passive program, depending on strength of repair, and surgeon, therapist preferences. This patient has only a two-strand repair. It would be most appropriate to undertake an early passive mobilization program such as the modified Duran protocol.1 This involves passive flexion of all digits combined with active extension of all digits to the limits of the splint in week 1 and 2. Then in week 3, a place and hold approach is used to facilitate limited isometric flexion of all digits. At week 6, active ROM of all digits can be commenced and from weeks 8 to 12, further strengthening exercises are undertaken. Active motion protocols, such as the Indiana protocol, can incur a higher incidence of rupture, but an improved ROM compared with passive motion protocols.2 However, these should be reserved for four strand (or greater) flexor tendon repair techniques.3 Of all the flexor tendon zones, it is zone 2 that would typically require the most intensive physiotherapy, although zone 1 injures will still require intensive and meticulous care (Table 88.1). Table 88.1 Modified Duran Protocol for Flexor Tendon Rehabilitation Modified Duran Protocol Orthosis: Forearm-based dorsal block splint, wrist in 20-degree flexion, MCPs at 40–50 degrees and IPs straight for 4–6 weeks Week 1: passive flexion of all digits and active extension to the limits of the splint Week 3: place and hold—limited isometric flexion of all digits using rubber band traction Week 6: active range of motion (AROM) of all digits Weeks 8–12: strengthening Thumb FPL (early passive motion protocol) Orthosis: Forearm-based dorsal block for thumb only, wrist in neutral, thumb MP at 30-degree flexion, thumb IP at 20-degree flexion Days 3–5: thumb passive flexion and active extension within the limits of the splint Week 3–4: thumb AROM Week 6: strengthening
position”? The traditional “intrinsic plus” hand position is designed to keep collateral ligaments and flexible joint structures in a suitably stretched position so that flexion contractures and subsequent stiffness are minimized. The wrist is held in 20 to 30 degrees of extension, the MCP joints in 70 to 90 degrees of flexion, and the IP joints in (or near to) extension. Following zone 5, 6, or 7 extensor tendon injury repair, the “safe” position is modified slightly to protect the repair at the MCP joint level. Therefore, while the wrist and IP joint angles are maintained, the MCP joint position is more extended at between 0- and 30-degree flexion according to surgeon and therapist preference. Some surgeons and therapist prefer to leave the IP joints free for early motion while the MCP joint is immobilized, whereas others use exercises within a full length splint to keep the IP joints mobile and allow some active MCP joint extension. Active ROM at the wrist is usually commenced at 4 weeks (Table 88.2).1 Table 88.2 Extensor Tendon Injury Zone of Injury Orthosis Protocol Zone 1 Mallet finger DIP in full extension or slight hyperextension, PIP free 6-week full-time wear Zone 2 Non-op and post-op Finger splint in full extension for 6–8 weeks Weeks 6–8: active range of motion (AROM) Week 12: passive range of motion (PROM), strengthening if indicated Zone 3/4 Boutonniere non-op Central slip injury: PIP extension splint full time for 4 weeks Central slip + lateral band injury: PIP + DIP extension splint full time for 4 weeks Central slip injury: Week 1: DIP A/PROM Central slip + lateral band injury: Week 4: DIP AROM Zone 3/4 Boutonniere post-op Finger splint in full extension until 6 weeks; Exercise template splint may also be fabricated allowing gradual PIP and DIP flexion Central slip repair: week 1: AROM of DIP Central slip + lateral band repair: limit DIP flexion 35 degrees Week 5: full digit flexion and strengthening Zone 5/6/7 post-op Forearm-based volar splint wrist in 30-degree extension; MPs at 0-degree extension, IPs free for 4 weeks Week 4: AROM wrist and digits Week 8: strengthening
Rehabilitation for scaphoid fractures will differ depending on whether the treatment is operative or nonoperative. For nonoperative cases such as low-risk stable scaphoid waist fractures, most U.S. protocols involve 8 weeks of immobilization within a forearm-based thumb spica, followed by active ROM exercises from weeks 8 to 12. Formal strengthening exercises can be commenced at 12 weeks. Many European protocols would instead use 6 weeks’ immobilization in a short-arm cast with the thumb free for a low-risk stable scaphoid fracture.1 In contrast, the other options listed all relate to the postsurgical management of scaphoid injuries, which can be mobilized earlier than nonoperatively managed fractures. In this scenario, the forearm-based thumb spica is used for the first 4 weeks. Then assisted active ROM can commence at 4 weeks, passive ROM at 6 weeks, and strengthening exercises at 10 weeks (Table 88.3).1–3 Table 88.3 Comparison of Scaphoid Fracture Management: Non versus Operatively (USA) Scaphoid Postoperative Orthosis Forearm-based thumb spica splint/cast full time 8 weeks Forearm-based thumb spica splint 4 weeks Weeks 8–12: AROM Week 2: wrist and thumb AROM Week 12+: strengthening Week 4: AAROM Week 6: PROM Weeks 10–12: strengthening
There are a number of key elements to assess during hand therapy after injury. These can be considered as those affecting range of motion (both active and passive), sensation, and strength. The dynamometer allows assessment of grip strength or pinch strength depending on the instrument used. Static grip strength (measured in pounds) is based on average consecutive trials and the recording is compared with non-injured hand. This can be used to determine return to work limitations as well as progression in recovery. Static pinch grip strength is also measured in pounds, and is performed in three positions: chuck, lateral, and tip.1 The passive and active ROM is measured using a goniometer, a device with two moveable limbs that facilitates measuring internal angles of joints in the lateral view. Again, joint function can be compared with the contralateral hand or standard values expected for any given joint. Semmes-Weinstein monofilaments are used to assess sensation by applying light touch to fingertips using five different thickness filaments, starting from thinnest to thickest and noting the first perception of touch. Muscle group strength may be tested against gravity using rubber bands. This is measured by strength scale (0/5–5/5): 0 = no movement; 3 = movement against gravity; 5 = movement against resistance. Precision of fingertip sensation can be assessed with two-point discrimination. With vision occluded, the ability to sense one as opposed to two points is assessed. It is usual to start 5 mm apart and increase as needed to record two-point sensation. In the normal uninjured hand, it is possible to discriminate less than 6 mm distances.1–4
Eighty percent of patients with distal radius fracture require hand therapy1 and common treatment plans include two to three sessions for a 6-week period.2,3 It is unclear if therapy beyond 12 weeks is beneficial after surgical intervention, although it may be for nonsurgical cases. Patients treated nonsurgically and those older than 65 years may simply benefit from being encouraged to return to activities of daily living as soon as possible.4 The protocols following distal radius fracture are shown in Table 88.4. Table 88.4 Distal Radius Fracture Management Nonoperative Postoperative Orthosis Sugar tong or Muenster splint 4–6 weeks then transition to a wrist splint for another 2–4 weeks Wrist splint for 4–6 weeks Week 1: digit and uninvolved joint A/ AAROM in splint Week 1: digit and uninvolved joint A/ AAROM Weeks 4–6: wrist, forearm, elbow AROM Week 2: wrist AROM, may want to hold forearm AROM depending on ulna Weeks 6–8: AAROM Week 4: AAROM Week 8: PROM, strengthening Week 6: PROM, strengthening
A Bennett fracture is a two-part fracture of the thumb metacarpal base that extends into the CMC joint.1 There is a volar fragment which is attached to the volar stabilizing ligament complex of the CMC joint, and the main metacarpal fragment tends to be pulled dorsally and radially with flexion of the shaft by forces from abductor pollicis longus and the thenar muscles in particular. It is the most common intra-articular fracture of the thumb and typically involves some form of hyper abduction of the thumb. Treatment may be operative or nonoperative depending on the fracture pattern stability. Reduction and stabilization is most often with K-wires and splint but may be performed with open reduction and internal fixation using screws or plates. Splinting the thumb is unlikely to lead to significant stiffness and even where stabilized with screws or plates, external splinting is still usually indicated. Therefore, protocol is normally the same whether operative or nonoperative treatment undertaken (see Fig. 88.3 and Table 88.5). Fig. 88.3 Reduction and stabilization of Bennett’s fracture using K-wires into the trapezium and index metacarpal base. Table 88.5 Bennett’s and Reverse Bennett’s Fracture Bennett’s (1st CMC) Reverse Bennett’s (5th CMC) Nonoperative Postoperative Orthosis: Bennett’s—thumb spica Orthosis: reverse Bennett’s—ulnar gutter Forearm-based thumb spica/ulnar gutter splint × 4 weeks Forearm-based thumb spica/ulnar gutter splint × 4 weeks Week 4: AROM AROM after pin removal Week 6: AAROM AAROM Week 8: strengthening Strengthening
Fractures of the metacarpals and phalanges can very often be managed nonoperatively with good functional results. Many fractures are minimally displaced and will not often need reduction. Where reduction is required, splint stabilization may be sufficient, but if not then K-wire fixation is often a good minimally invasive choice. A downside is that postoperative splinting is usually still required. In contrast, fractures that are stabilized with ORIF in the form of screws and/or plates can often be managed without external splintage and should be mobilized early postsurgery to reduce the risk of adhesions forming to the plate and cutaneous scar. The ability to mobilize early depends on many factors such as stability of the fixation, the quality/stability of the soft tissues, and the reliability of the patient. While mobilization can commence earlier, there is no certainty that outcomes will be better in the longer term. Postinjury pain and swelling are probably increased by the trauma of surgery and aesthetically ORIF can often be worse; e.g., a dorsal approach to a metacarpal fracture will leave a permanent and visible scar and the plate may be palpable or even visible. Patients should be counseled that ORIF may require secondary surgery in the form of tenolysis or removal of hardware in the future (Table 88.6).1 Table 88.6 Metacarpal and Phalangeal Fractures Metacarpal Postoperative Orthosis Distal: MPs at 70 degrees, IPs free Proximal: forearm-based radial/ulnar gutter, MPs at 70 degrees, IPs free Distal: MPs at 70 degrees, IPs free Proximal: forearm-based radial/ulnar gutter, MPs at 70 degrees, IPs free Week 3—AROM Week 3—AROM after pin removal Week 6—PROM, strengthening Week 6—PROM, strengthening Proximal phalanx Postoperative (pinning) Orthosis Hand-based ulnar/radial gutter MPs at 70 degrees and IPs straight for 4 weeks Hand-based ulnar/radial gutter MPs at 70 degrees and IPs straight for 3 weeks Week 3: AROM of MPs and IPs Week 1: AROM of uninvolved MPs and IPs Week 4: AAROM of MPs and IPs, buddy taping when out of the splint Week 2: AAROM of uninvolved MPs and IPs Week 6: strengthening Week 3: AROM of fractured joint once pin is removed Week 6: strengthening Middle phalanx Postoperative (pinning) Orthosis Hand-based radial/ulnar gutter MPs at 70 degrees and IPs straight for 3–4 weeks; may consider finger splint in full extension for 4 weeks Hand-based radial/ulnar gutter splint MPs at 70 degrees and PIP in pinned position Week 1: AROM of uninvolved MPs and IPs Week 1: AROM of uninvolved MPs and DIPs Metacarpal Postoperative Weeks 4–6: AROM of involved IPs when stable Week 3: AROM of PIP once pin is removed Week 8: PROM, strengthening Week 4: AAROM Week 6: PROM, strengthening Distal phalanx, bony and soft-tissue mallet finger injuries Postoperative (pinning) Orthosis Finger splint with DIP in full extension or slight hyperextension, PIP free, full-time wear for 6 weeks Finger splint to protect pin, PIP free 6 months*—wean to wear orthosis only at night, PIP AROM Days 3–5: PIP AROM Week 3: AROM of DIP once pin is removed Week 6: gradual strengthening if required, care must be taken to ensure that DIP remains in extension and does not lag *Skin care important during this time.