CASE 9: Hand Therapy Flashcards
(13 cards)
Where does zone 2 extend from?
What is in Zone 2?
Distal palmar crease (A1 pulleys) to insertion of FDS on middle phalanx
In zone 2: A2 and A4 pulleys. Both FDP and FDS tendons within a fibro-osseous tunnel (sheath)
What is extrinsic healing?
Fibroblasts and inflammatory cells from surrounding sheath/tissues enter the tendon via synovial fluid = produces adhesions
What is intrinsic healing?
Activity of tenocytes within the tendon itself - more desirable (better glide, less scarring)
Effects of controlled mobilisation
- Decreases adhesions
- Increased tendon healing
- Increased strength and tensile quality of tissue
When should exercise rehabilitation start?
Within 3-5 days post-op.
Starting too soon ie < 3 days = oedema will increase work of flexion.
> day 7 = adhesion formation & tendon softening (too late!)
How often should rehab occur?
Usual practice 5-10 repetitions 2nd hourly.
Evidence has shown increased frequency and duration is superior eg recent study: Tang 2021 = 40-80 repetitions 4-6 times per day
How far ie degrees for DIO/PIP motion?
AIM is 3-5mm of excursion at repair site.
- 1.5mm of FDP excursion for every 10 deg of DIP motion
- 1.5mm of FDS excursion for every 10 deg of PIP motion
= aim for minimum 20 deg of DIP/PIP flexion
What is the goal by Week 1 and Week 4 for PIP/DIP flexion ROM?
Week 1:
- 30 deg PIP flexion
- 5-10 deg DIP flexion
Week 4
- 80-90 deg of PIP flexion
- 50-60 deg of DIP flexion
What does rehabilitation from Day 2-4 up to Week 4-6 consist of?
Splinting
- Wrist 20 deg extension
- MCJ 30-45 deg flexion
- IPJ full extension
Exercise (2-5 reps)
- Full passive flexion PIP/DIP
- Active flexion PIP/DIP
- Active extension PIP/DIP
What does rehabilitation consist of from week 4-6 up to week 12?
- FDP Blocking
Action: Actively flex the DIP joint only while keeping the MCP and PIP extended.
Goal: Glide FDP tendon. - FDS Blocking
Action: Actively flex the PIP joint only while keeping the DIP extended.
Goal: Glide FDS tendon. - Towel Walking
Action: “Walk” fingers forward and backward on a towel, moving one joint at a time.
Goal: Promote controlled joint flexion and coordinated tendon glide. - Sponge Squeezing
Action: Gently squeeze a soft object with the whole hand, hold for 3–5 seconds, then relax.
Goal: Begin gross grip re-training with light resistance. - Light Putty Squeezes (dynamic ie squeeze & release)
Action: Gently squeeze or pinch putty between fingers or with the whole hand.
Goal: Activate flexors safely with gentle resistance. - Sustained Gripping eg therapy ball
Action: Hold a light grip for 5–10 seconds, then relax.
Goal: Build endurance and control in flexor tendons.
Note: From W4 tendon repair gains tensile strength (though still weaker than normal), allowing for more active motion.
Risk of repair rupture decreases (especially if early protocols like Kleinert or Duran have been followed properly).
Blocking allows gliding of the individual tendons and promotes independent control - pt is performing DIP/PIP flexion
When is the splint discontinued?
At 4 weeks if poor glide
At 5 weeks if goals achieved
At 6 weeks if full fist by 2 weeks
Note: If a patient has poor ROM and they are strongly scarred you can take the splint off at 4 weeks to allow them to do some light functional exercises to facilitate improved glide.
Dorsal blocking Splint
- Purpose (Hint: 2)
- Worn how long?
- Can be removed for…
- limits finger and wrist ext & prevents rupture of healing tendon
- Usually worn full-time for 4-6 weeks
- Can be removed for hygiene & supervised exercises
What is the formula for total active movement (TAM - outcome measure)
Scoring?
(PIP + DIP flexion) - (extension deficits) divided by 175 and expressed as a %
Poor = 0-24% = <44 deg
Fair = 25-49% = 44-87 deg
Good = 50-74% = 88-131 deg
Excellent = 75-100% (132 deg)
**TRY remember to include in any hand assessments! Consider from W6 - not earlier.
