Hand deformities

Musculoskeletal system
Orthopedics
physiotherapy management of Hand Deformities

1. HAND DEFORMITIES DR. SEJAL SAILOR. M.P.T.(ORTHO )

2. MALLET FINGER

3. Mallet finger is a common injury usually due to forced flexion of the distal phalanx while the extensor tendons are actively trying to extend the finger. Mallet finger injury is a traumatic disruption of the terminal tendon that results in a loss of active extension of the distal interphalangeal (DIP) joint.

4. Also known as Baseball finger, Drop finger, Cricket finger. The baseball catcher, football receiver and others are vulnerable to this injury. Depending upon whether the thin extensor tendon is torn in its substance or pulls off a small piece of bone at its insertion, two types are recognized: Mallet finger of tendon origin. Mallet finger of bony origin.

5. Tendon Origin This is due to loss of extensor tendon continuity at the distal finger joint.

6. Mechanism of Injury Here the end of the finger is forcibly flexed, when extensor tendon is taut, e.g. while tucking the bed, catching a ball, striking an object with extended finger, etc.

7. Clinical Features Pain, swelling, tenderness, flexion deformity of the tip of the finger and Inability of the patient to actively extend the finger at the distal PIP joint.

8. Several Types Extensor tendon stretched Extensor tendon ruptured Avulsion fracture

9. Extensor tendon stretched in this, degree of drop is less. There is loss of 5 to 20° of extension. There is weak active extension. Extensor tendon ruptured from its insertion into distal phalanx. There is 40 to 45° loss of extension. No active extension. Avulsion fracture . A small fragment of distal phalanx is avulsed with the extensor tendon. There is no active extension and it should be treated as tendon injuries rather than fractures. If the flexion deformity is severe, a secondary hyperextension deformity of PIP joint occurs, because of imbalance of the extensor mechanism.

10. Radiographs X-ray of the affected finger may show an avulsion fracture of the dorsal lip of the base of the distal phalanx.

11. Treatment Nonoperative measures: This is reserved for pure dislocations, collateral ligament injuries and mallet finger. Various custom-made dorsal hyperextension splints (Mallet splints) are used for immobilizing the DIP joints.

12. Closed reduction and percutaneous fixation: This is reserved for mallet injuries in professionals like dentists, surgeons, sportspersons, etc. who cannot keep their fingers immobilized for long due to professional commitments.

13. Open reduction and internal fixation: Avulsion of the profundus tendon and its reinsertion. Chronic subluxation of the DIP joint (> 3 weeks). Irreducible dislocations.

14. A stack plastic mallet finger splint Distal joint is put in slight hyperextension. The splint may cause pain and the amount of hyperextension should not cause blanching of the skin over DIP joint. Splints are useful in cooperative patients, and in uncooperative patients. Smellie’s cast is used. About 6 to 10 weeks of continuous immobilization is required. K-wire fixation is considered in patients like dentist or surgeon who wants to return to work quickly.

15. Mallet Finger of Bony Origin This is less common. It is usually fixed with K-wire, if more than one-third of the dorsal articular surface is involved and if remainder of the distal phalanx is subluxated volar-wards.

16. Treatment Goals Promote healing of terminal tendon. Maintain full ROM of all uninvolved joints of the upper extremity. Prevent or correct swan-neck deformity and DIP joint flexion contracture. Maximize ROM of DIP joint and PIP joint; in particular, maximize active DIP joint extension. Return to previous level of function. Prevent reinjury.

17. Nonoperative Therapy Management of closed treatment with full passive DIP extension available. (If full passive DIP extension is not available, static progressive splinting will be necessary before initiating this timeline.) Weeks 0 to 8: Continuous splinting in 0 degrees or slight hyperextension (see Splints). Change adhesive tape and check skin regularly.

18. Weeks 8 to 10 : Continue day and night splinting. Begin active flexion up to 25 to 30 degrees. May use a volar template to limit flexion during exercise. Weeks 10 to 12 : If there is no extension lag, discontinue day splint but continue night splint. If extension lag persists, balance splinting and exercise to minimize lag.

19. Week 12 : Begin unrestricted use. Continue to monitor for extension lag; if lag returns, reinstitute appropriate level of splinting (night only versus day and night) for additional 2 weeks.

20. Splints Position DIP joint at 0 degrees or slight hyperextension Hyperextend DIP joint without blanching dorsal skin. Splints may be on dorsal surface, on volar surface, or circumferential. A gutter splint for the PIP joint may also be indicated if significant swan-neck deformity coexists.

21. Splint types 1. Custom thermoplastic 2. Alumafoam 3. Stack

22. Postoperative Therapy General care Oedema control Wound care Scar management Pain management Maintain ROM of uninvolved digits. Protect surgical repair.

23. Weeks 0 to 6 K-wire or button intact ROM of uninvolved joints Pin site care

24. Weeks 6 to 8 K-wire removed Begin active range of motion (AROM) and follow closed Treatment as described earlier (see Nonoperative Therapy). Extension splinting for 2 weeks

25. Jersey finger It is due to avulsion of flexor digitorum profundus from its insertion on distal phalanx. This is the opposite of ‘mallet finger’ and the patient is unable to flex the distal interphalangeal joint. It is seen in football and rugby players .

26. SWAN-NECK DEFORMITY

27. Swan-neck deformity is a deformity in which the PIP joint is hyperextended and the DIP joint is flexed.

28. The causes of these factors include Rheumatologic disease, Extensor terminal tendon injuries (mallet finger), Spastic conditions, Severe intrinsic tightness, Injuries that cause volar plate laxity, fractures to the middle phalanx that heal in hyperextension, and Generalized ligamentous laxity

29. The deformity may also occur secondary to surgical procedures such as a flexor digitorum profundus (FDP) graft in which the flexor digitorum superficialis (FDS) is absent.

30. Treatment and Surgical Purpose Splinting of the PIP joint in a flexed posture may be used temporarily to prevent fixed contractures and restore extensor tendon and joint capsule balance by promoting volar plate tightening. Active therapy may be beneficial in regaining balance in soft tissue structures that may be contributing to the condition. Surgical correction may be necessary for restoration of the extensor balance, including central slip tenotomy, PIP joint arthroplasty, and PIP joint arthrodesis.

31. Treatment Goals Nonoperative Promote balance of the extensor mechanism. Reduce intrinsic tightness. Maximize joint ROM. Maintain ROM of wrist and uninvolved digits.

32. Nonoperative Therapy AROM/PROM Intrinsic stretching exercises Splint to balance finger extension. A tripoint splint prevents PIP joint hyperextension and restores DIP joint extension. This type of splint places dorsal pressure proximal and distal to the PIP joint and volar pressure at the PIP joint. It allows full active flexion. Custom figure 8 splint Silver ring splint Oval 8 splint

33. Postoperative Therapy General care Edema control Wound care Scar management Pain management Maintain ROM of uninvolved digits. Protect surgical repair.

34. Treatment after passive procedures for PIP joint flexion Weeks 0 to 6 postoperatively The PIP joint is splinted at 30 degrees flexion with the DIP joint at 0 degrees. Active motion that allows full flexion and limits extension of the PIP joint to 30 degrees begins 3 to 14 days postoperatively. A Kirschner wire (K-wire) or splint may be used to hold the DIP joint in extension to facilitate maxima PIP joint flexion. Splinting to improve PIP joint flexion may be initiated, if necessary, at 3 weeks postoperatively.

35. Weeks 6 to 10 postoperatively The splint is gradually adjusted to allow increased active extension, or the patient is permitted to decrease use of the splint. Passive extension exercises for the PIP joint are rarely necessary, because PIP joint extension typically increases gradually over several months. (A slight limitation in PIP joint extension is acceptable and expected.)

36. Dynamic extension splinting may be initiated at 8 weeks for PIP extension limitation greater than 30 degrees. Strengthening for flexion may begin at 6 to 8 weeks. Other procedures: Swan-neck deformity in rheumatoid arthritis commonly requires treatment by PIP joint arthroplasty.

37. Operative Complications Infection Excessive oedema Pain Rupture of tenodesis Attenuation of tenodesis Excessive scarring Limited ROM

38. BOUTONNIERE DEFORMITY

39. The boutonniere or “buttonhole” deformity occurs when the central slip of the common extensor tendon is damaged at its insertion onto the base of the middle phalanx. Volar subluxation of the lateral extensor bands palmar to the axis of motion of the PIP joint occurs secondary to the force imbalance.

40. A boutonniere deformity is a deformity in which a digit assumes a posture of conjoint PIP joint flexion and DIP joint hyperextension.

41. The PIP joint eventually herniates through the extensor mechanism, with resultant stretching of the spiral fibres and transverse fibres. Progression of the deformity may lead to compensatory MCP joint hyperextension.

42. The distal phalanx also becomes involved as the oblique retinacular ligament undergoes adaptive shortening and the DIP joint is held in hyperextension. The boutonniere deformity can result from injuries caused by division, rupture, avulsion, laceration, or closed trauma to the central extensor tendon inserting onto the middle phalanx. Dorsal burns, rheumatoid arthritis, Dupuytren’s contracture, and congenital disease are other causes

43. Despite different classifications and numerous surgical techniques for correction of the boutonniere deformity, it appears that most authors’ treatment of choice is conservative long-term hand therapy to increase PIP joint extension and DIP joint active full flexion through the use of splinting. Only if an acute, open injury occurs should immediate surgery be performed.

44. Treatment Goals Prevent extensor tendon complete rupture. Reduce swelling and pain. Prevent PIP joint flexion contracture. Prevent lateral band subluxation. Prevent oblique retinacular ligament contracture. Restore AROM/PROM of MCP, PIP, and DIP joints. Maintain ROM of uninvolved joints of the upper extremity. Return to previous level of function

45. Nonoperative Therapy Management of deformity with full passive PIP joint extension available (If not available dynamically, static progressive splinting or serial casting is required to regain full PIP joint extension before initiating this timeline.)

46. Weeks 0 to 8: continuous splinting with PIP joint at 0 degrees and DIP joint free. Regular performance of DIP joint flexion exercises within splint Monitor skin integrity regularly Joint mobilization may be necessary to maintain capsular mobility without allowing flexion of the PIP joint.

47. Weeks 8 to 10: Continue day and night splinting. Begin active flexion of 30 to 40 degrees, with 10- to 20-degree increase weekly as tolerated. May use a volar template to limit flexion during exercise. Continue with DIP joint flexion exercises in splint. Continue to monitor skin integrity.

48. Weeks 10 to 12: If no PIP joint extension lag exists, discontinue splinting; if extension lag persists, balance splinting and exercise to minimize lag. Week 12: Begin unrestricted use. Continue to monitor for extension lag; if lag returns, reinstitute appropriate level of splinting (nigh only versus day and night) for additional 2 weeks. Incorporate strengthening and dynamic flexion splinting only as necessary.

49. Splints A. Corrective splints to regain full passive extension 1. Dynamic 2. Static progressive or serial casting. B. Static splints: Position PIP joint at 0 degrees and allow full motion at the MCP and DIP joints. C. Splint fasteners 1. Adhesive tape 2. Velcro (limited control against rotation and distal slippage)

50. Operative Indications/Precautions Indications A. Failure of conservative treatment for longer than 6 months Precautions A. Complicated wounds B. Infection C. Fractures D. Maximal pain E. Severe oedema

51. Postoperative Indications/Precautions Indications A. If K-wire is used, protect with splint B. Wound care C. Edema reduction D. Restore DIP joint flexion

52. Postoperative Therapy Depending on the stage of deformity and the surgical procedure, postoperative treatment may vary significantly. It is important to discuss the operation performed as well as specific restrictions with the physician before initiation of a therapy program.

53. Weeks 0 to 4 A. Splint or K-wire is used to maintain full PIP joint extension. B. Active DIP joint flexion is encouraged to promote adhesion-free gliding of the lateral bands through the postsurgical scar. C. Scar management

54. Weeks 4 to 6 A. PIP joint extension splinting continues at all times (except during exercise). 1. Dynamic extension splinting during the daytime (may use check-rein to control flexion limit) 2. Static extension splinting at night B. Gentle AROM of the PIP joint into flexion is initiated along with active-assisted or passive extension (depending on surgical procedure). C. Scar management

55. Weeks 6 to 8 A. Gradually wean from the splint during the day, with continued night time use as needed to control extension lag. B. Closely observe for PIP joint lag. If lag resumes, splinting is continued during the day as well as at night for an additional 2 weeks. C. Continue to advance AROM through activity and exercise.

56. Weeks 8 to 12 A. Splinting at night if lag persists. Dynamic or static PIP flexion assistance may be initiated as needed (must be monitored closely as not to increase PIP joint extension lag). B. AROM continues; may initiate gentle strengthening exercise to facilitate PIP joint flexion.

57. Weeks 12+ A. Night splinting may be necessary for several months as the tensile strength of the repair increases. B. Initiate progressive strengthening activities as needed.

58. Postoperative Complications Infection Severe edema Maximal pain Rupture of the repair

59. Thank you